Journal of Trauma & Orthopaedics – Vol 5 / Iss 3 by British Orthopaedic Association

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 05 / Issue 03 / September 2017 boa.ac.uk

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Read the News and Updates section for the latest from the BOA and beyond

In our Features section, you will find articles that focus on research, training, the logbook, the SAC agenda and delivering high impact presentations for surgeons

For the latest update on our clinical issues, see our Subspecialty section; the focus of this issue is engineering, plus our regular “How I…” piece

News & Updates ––– Pages 02-27

Features ––– Pages 28-59

Subspecialty Section ––– Pages 60-70

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JTO News and Updates

From the Editor

Contents

Phil Turner Effective practice in our specialty relies on an understanding of the scientific principles that underpin the disease processes we treat and the interventions we make. In this issue we have three articles that bring us up to date on aspects of engineering that are intimately related to outcomes. Our Guest Editor, Tony Miles, has brought us thought provoking themes from leaders in their fields. The recent mantra of reducing variation to improve efficiency and effectiveness suggests that the improved accuracy and consistency achieved by using robotics may be a way forward. Brian Davies provides us with a concise history and commentary on the present status of this fascinating yet poorly understood area.

Research and innovation are at the centre of improving patient outcomes. The BOA historically provided small grants to support projects but the impact was uncertain and led us to thinking differently about how we should support it. The funding of the British Orthopaedic Research Centre was the result and Amar Rangan explains how this has totally transformed the orthopaedic clinical trials landscape and encourages the next generation of researchers. We now have 18 Orthopodcasts and I would like to direct you to the most recent one from Eva Doherty. Working under pressure with limited resources puts increasing pressure on us all and she provides practical advice on coping with stress and improving resilience. At Congress we are recognising the outstanding contributions from four of our members by the award of Honorary Fellowships and the Presidential Merit Award. Their achievements should inspire all of us. Each of them is an excellent communicator and Lisa Hadfield–Law provides the rest of us with some timely advice on preparing and delivering high impact presentations. I will be checking up as I go round Congress and hope to meet as many of you as possible.

JTO News and Updates

02–27

JTO Features

28–59

An update on the British Orthopaedic Surgery Research Centre (BOSRC)

Winner of the 2017 Robert Jones Medal and Association Prize

Who needs a logbook?

SAC Agenda

Operations I no longer do… Conventional posterior approach for total hip replacement

National Joint Registry Data Quality Audit

How I Do… Percutaneous Fixation of Depressed Intra-Articular Calcaneus Fractures

High Impact Presentations for Surgeons

Supporting Student-Led Orthopaedic Conferences Improves Understanding and Perceptions of the Field

The Junior Doctor’s Contract; What’s Happening Now? 52 Conferences in medico-legal cases - don’t get ambushed 56

Subspecialty Features

Modularity in Orthopaedics

60–70 60

Orthopaedic Robotic Surgery

Hydroxylapatite Coatings for Fixation of Orthopaedic Implants to Bone

In Memoriam

General information and instructions for authors

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JTO News and Updates

From the President Ian Winson, BOA President Well a year as President has flown by and just when you are getting the impression you are making a difference (little steps!) suddenly you realise you will be handing over the gong. I guess many Presidents get to this point and think, but there is more... Actually what you realise is two things are for certain: having a Presidential line that stretches back, as of next year, 100 years; and you see the quality of the people who will follow you there are reasons to believe we can endure and continue to have impact by “Caring for Patients, Supporting Surgeons”. The theme of Quality and Innovation are the key to us continuing to fulfil that mission statement. There is a growing pressure on the government to accept that we have an absolute interest in delivering a quality service and the contribution T&O makes to maintaining and maximising that service, the greater the positive benefit to the economy. We need to make the service efficient (which is an expression of consistency) while making sure it delivers accurately what patients want. The more the evidence grows that that is what we aspire toward, the more it becomes difficult for those away from the clinical front line to argue that the deficiencies of the health service are all the clinicians fault.

Ian Winson

Measuring quality is not easy on two fronts: Firstly, using the right measures and secondly, getting enough data to make it significant. Getting enough data is about us getting involved. Critically we have through the process of working out

the rules of clinician based registry data acquisition much better understanding of the legalities of how this works. Making sure we use this knowledge will drive us to a better understanding of how our patients benefit from their treatment. Ultimately, though to get progress in MSK care to evolve has to be driven by innovation. The problem is that no matter how far one goes to make appropriate safety and efficacy assessments prior to their clinical use, human beings are the most effective test method. As a consequence, the process of innovation will always be more risky than sticking with what we have now. Therefore any innovative change should be the subject of study. This includes processes such as Beyond Compliance and ODEP. There are some realities we are going to have to chase down and change the nature of the arguments. Going through a process that seeks to improve efficiency is clearly worthwhile and on a patient by patient basis will increase the accuracy of treatment thus saving costs. But the idea that the money is then withdrawn because it isn’t necessary is simply wrong just on the basis that we have a growing population of patients who would benefit

from accurately provided MSK treatment. Reducing the Trauma and Orthopaedics monies in total through the NHS will produce a significant reduction in the quality of life (and their personal ‘productivity’) for tens of thousands of patients. It is no good to say, as has been argued, that historically orthopaedic units have made money for hospitals. Again that is an argument for selectively reducing tariff. It is a simple truth that all of the country patients are being prevented from access to orthopaedic surgery in order to save costs. The fact that CCG’s are ignoring well researched NICE guidelines to put barriers into pathways that have no justifiable basis can only be to try and balance their budgets. The purpose of efficiency exercises with the present population requirements should be to be able to accurately treat more patients. With the best will in the world that is not going to happen with a 13.5% reduction in the total budget. The growing litigation pressure is similarly not a measure of decreasing performance in T&O. It is a measure of the growth of the blame culture, this means that the NHS doesn’t have a learning culture and further compromises any accurate delivery of patient care. It is not just a case of a growth of a risk adverse culture. It is much more about accurate care means a culture open to the discussion of error. That won’t happen if we are hiding the errors for fear of criticism. The Congress will look at many aspects of Quality and Innovation, hopefully it will help to drive us forward. n

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JTO News and Updates

Incoming President - Ananda Nanu As I step into the post as President of our Association, I am deeply honoured to be the 100th person to lead the BOA. Our centenary year will end with our Congress in Birmingham from the 25th of September 2018, and I will endeavour to reflect the changes in our role, not only as Orthopaedic surgeons, but also as guardians of what we believe is the right way to treat musculoskeletal ills.

Ananda Nanu

As I step into a pair of well used shoes liberated by Ian Winson, I am all too aware of the rapidly changing health environment that impacts on how we deliver healthcare. Funding healthcare is an issue that will continue to occupy our political minds, and it would be reasonable to say that there is no likelihood of more money for bone and joint disorders during my term as President. Inefficiencies in our systems of delivery are

gradually being ironed out, but are sometimes negated by a rise in micromanagement. There is a large and inert layer of soundproof padding between primary and secondary care that belies the National in NHS. As clinicians, we have concentrated on acquiring those skills and techniques that serve our individual patients so well, and that attract citizens of other countries to seek musculoskeletal care in our country. We also need to drive management change by leading initiatives to improve quality and efficiency in our processes. I believe that the specialist societies are the powerhouse of the academic aspirations and interests of our members. I also believe that we need to work with our specialist societies, listening to them and working through the issues that they have in common, preventing duplication of effort on

common issues. The BOA hopes to echo the concerns and project the forward plans of our specialist societies on a political stage. I intend to link our council more closely to the BOA, involving them closely in the running of our organisation. I intend to seek out those of our workforce who carry the load of everyday work on their shoulders, but feel disenfranchised and disillusioned by the political aspects of healthcare and involve them more closely in our organisation. And lastly, I intend to work closely with our colleagues currently in training, to invigorate the BOA with their experiences and enthusiasm. I hope to meet you personally and look forward to seeing you at our Congress. n

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The BOA honours outstanding members The BOA is pleased to announce the recipients of the 2017 Honorary Fellowship and Presidential Merit Awards, which will be presented at the Annual Congress in Liverpool. a consultant at Ormskirk District General Hospital and Wrightington Hospital, where he set up the hand unit, focussing on rheumatoid disease and general wrist problems.

Andrew Amis – Honorary Fellowship

Andrew A. Amis FREng, PhD, DSc(Eng), FIMechE, CEng is Professor of Orthopaedic Biomechanics and head of the Medical Engineering group of Imperial College London. He is based at the Mechanical Engineering Department and the Musculoskeletal Surgery Group in the Department of Surgery and Cancer. He has worked in orthopaedic biomechanics for more than 40 years and has published extensively, largely relating to sports knee problems and development of joint replacements and instrumentation. His work ranges from basic anatomy through biomechanical analysis of the functions of specific tissue structures to joint and patient function. This has led to many patented inventions for surgical procedures and implantable devices. He has widespread collaborations with surgeons and industry. Current works include development of a total shoulder prosthesis system, meniscal repair methods, directing a spin-out company developing a meniscus prosthesis, and development of ligament repair/reconstruction methods to address rotatory instability of the knee.

Clare Marx – Honorary Fellowship

Clare Marx, an orthopaedic surgeon, works as Associate Medical Director in Ipswich Hospital NHS Trust. After her Chairmanship of the Trauma and Orthopaedic Specialist Advisory Committee, during which the new T&O curriculum was written, she went on to be President of the British Orthopaedic Association 2008-9. She has a keen interest in the Patient Safety agenda and chairs the College Invited Review Mechanism. Also high on her agenda are workforce issues, particularly the low percentage of women entering surgery, the challenges of delivering quality training in reduced working hours, and the need for professionals to continuously strive for improvements in quality and care of their patients.

He has held a number of prestigious positions within the profession, including Vice President of the Royal College of Surgeons of England, President of the British Society for Surgery of the Hand, President of the British Association of Hand Therapists, and Honorary Member of the British Society for Surgery of the Hand. Professor Stanley was appointed ad hominem Professor of Hand Surgery at the University of Manchester in 1996 and has held visiting professorships around the world. In 2016, the International Federation of Societies for Surgery of the Hand presented him with the Award of International Pioneer in Hand Surgery.

Professor W Angus Wallace – Honorary Fellowship

Professor John Knowles Stanley – Honorary Fellowship

Professor Stanley attended Liverpool University Medical School, and received his MCh Orth in 1977. In 1979, he became

Professor Wallace, currently Regional Director for the East Midlands, has had a long and prestigious orthopaedics career in Scotland and England. He is well-known for his long tenure as Professor of Orthopaedic and Accident Surgery in Nottingham. Professor Wallace was instrumental in developing a number of innovative medical devices, including the LockDown and Infinity-Lock. Heavily

involved with air, rail, and road accident investigation, he has contributed research, leadership, and expert advice to numerous high-profile investigations. He has held a number of prestigious positions in the profession and been asked to deliver presentations around the world.

Stephen Mannion – Presidential Merit Award

Stephen Mannion’s courageous career has led to him being described as the “Indiana Jones of surgery”. After graduating from Cambridge, he worked for Médecins Sans Frontières in conflict situations in Afghanistan, Cambodia, Angola, Sri Lanka, Ethiopia, and Rwanda. He later continued his studies at Guy’s and St. Thomas’s and in San Antonio, Texas. He returned to Malawi for three years as a medical missionary, and eventually founded the Feet First charity to promote the rational management of talipes in developing nations. He remains involved with charities that support musculoskeletal problems and the provision of wheelchairs and prosthetics. He continues to work with Médecins Sans Frontière and heads the Department of Conflict and Disaster Medicine at St George’s. He retains an orthopaedic surgeon job share at Blackpool and Fylde Hospital, but spends much of his time attending disaster zones, or visiting clinics in Malawi and Nepal.

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JTO News and Updates

BOA Latest News BOA Travelling Fellowships We are pleased to once again offer up to 20 Travelling Fellowships to BOA members. These fellowships offer trainees the opportunity to benefit from the knowledge, experience, and different cultural perspectives within trauma and orthopaedic surgery in centres of excellence abroad. Applications for the 2018 Travelling Fellowships open in September 2017. For further information, please visit www.boa.ac.uk/training-education/boa-travelling-fellowships/.

BOA Instructional Course 2018 The Instructional Course is a highlight of the BOA’s calendar, and we are pleased to announce registration is now open for 2018. This course brings together all levels of postgraduate trauma and orthopaedic trainees to prepare for their FRCS examination and to gain experience in a number of clinical case based discussions (CBDs). This year’s course will focus on the foot and ankle, spine, pelvis and acetabulum, sarcoma and trauma. Places are extremely limited, so we encourage those interested in the 2018 course to register as soon as possible at www.boa.ac.uk/events/instructional-course/.

Hip Fracture Review Training Day SAVE THE DATE: Tuesday 5th December 2017 Venue: De Vere Venues, Colmore Gate, Birmingham

FREE TO ATTEND The BOA is running an all-day Hip Fracture Review Training event. The aim of the training day is to understand the BOA’s coordinated hip fracture review process, reflect on the reviews undertaken to date and to consider future direction. The day would benefit all healthcare professionals involved in hip fracture care and who wish to be involved in the reviews. For further information and to register please visit www.boa.ac.uk/pro-practice/multidisciplinary-hip-fracture-review/. For any enquiries please contact Natasha Wainwright on n.wainwright@boa.ac.uk.

New Orthopodcasts Episode 17: Bullying in the Orthopaedic Workplace In this episode, Fergal Monsell (paediatric orthopaedic surgeon in Bristol) presents some interesting views on addressing bullying and harassment within the surgical workplace. How did we get here and where are we going? The issues of bullying, undermining and harassment within the surgical workplace was recently highlighted by the BOTA, which came as a shock to many who considered these to be problems of the past. Do they really still exist? To find out, listen at www.boa.ac.uk/orthopodcast/episode-17bullying-in-the-orthopaedic-workplace/. Episode 18: Managing Stress and Burnout In our 18th Orthopodcast, Eva Doherty (Director of Human Factors in Patient Safety at the National Surgical Training Centre at the Royal College of Surgeons in Ireland and practising Chartered Clinical Psychologist) explores how to prevent and interrupt the damage caused by negative stress, using simple techniques you can put into practice right away. Eva uses her vast experience with large and small groups to talk about breathing control, mindfulness, muscle control and cognitive techniques. You can listen to the Orthopodcast at www.boa.ac.uk/orthopodcast/ episode-18-managing-stress-burnout/.

Training Orthopaedic Trainers Course The Training Orthopaedic Trainers (TOTs) course will be held on the 12th and 13th of October 2017 in Newcastle. The TOTs course was established to improve the standard of teaching for those in trauma and orthopaedic (T&O) training and practice. The course is based on the premise that if T&O trainers better understand the workings of the T&O curriculum and how people learn, they can translate that into higher quality teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. If you are interested, please visit www.boa.ac.uk/events/training-orthopaedic-trainers/.

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BOA Appointments We are pleased to announce the following appointments: l BOA President for 2019/20: Donald McBride l BOA Honorary Treasurer for 2018-2020: John Skinner l BOA Trustees for 2018-2020: Peter Giannoudis, Rhidian

Morgan-Jones, Hamish Simpson, Duncan Tennent

UK and Ireland In-Training Examination (UKITE) Since February 2017 we have been developing a new UKITE platform and we are pleased to update you that the migration is almost complete. The UKITE will sit on a more streamlined and user-friendly platform supported by Moodle LMS. The UKITE has been integrated into the BOA membership since 2014. The UKITE is a national, online examination providing immediate results to trainees and allows practice for the ‘real’ FRCS T&O examination with similar formatted questions based on the UK T&O curriculum. For information regarding the UKITE please contact ukite@boa.ac.uk.

Clinical Leaders Programme The BOA National Clinical Leaders Programme (CLP), which is now in its third year, offers members a chance to develop their leadership capability within the context of quality improvement in orthopaedic services. The programme will run in four two-day modules between October 2017 and June 2018 in Newcastle upon Tyne. The course is a combination of master classes, tutorials, and coaching sessions with experts. Those interested can apply individually, via their trust, or through a specialist society sponsoring the programme. Applications will open in autumn 2017. For further information, please visit www.boa.ac.uk/trainingeducation/boa-national-clinical-leaders-fellowships-programme/.

New position statements on rationing and access to surgery The BOA published a position statement entitled ‘Arbitrary Barriers: Rationing of Orthopaedic Services’, which updates the BOA position on CCG policies that limit or delay orthopaedic surgery based on smoking status, BMI, or Oxford Scores. We are concerned that the number of such policies are growing; our view remains that these arbitrary barriers are unjust, not based on clinical evidence, and liable to cost the NHS more in the longterm. Available online at www.boa.ac.uk/publications/arbitrarybarriers-rationing-of-orthopaedic-services-09-08-17/. The BOA is also backing a new position statement led by ARMA (the Arthritis and Musculoskeletal Alliance) on this topic, entitled “‘Rationing’ - Access to Joint Replacement Surgery and impact on people with arthritis and musculoskeletal conditions”. This paper observes that “Delays to surgery can have multiple consequences for the patient: it can mean they don’t have such a good outcome from the surgery, as well the extended wait resulting in muscle wasting due to immobility, reduced cardiovascular fitness, osteoporosis due to immobility and adverse effects on the patient’s mental health […] The long-term use of analgesic, opioids or NSAIDs (non-steroidal anti-inflammatory drugs) can have significant side-effects, with long term opioid addiction being a real risk.” Available online at www.arma.uk.net/arma-policy-position-paper-on-jointreplacement-surgery/.

Training Orthopaedic Clinical and Educational Supervisors (TOCS & TOES) Course This course provides delegates with a range of learning outcomes, all of which are mapped to the seven domains underpinning the GMC requirement for recognition as educational and clinical supervisors. The next TOCS and TOES course will be held at the BOA offices on 8th November 2017 and will be facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. If you would like to sign up, please visit www.boa. ac.uk/events/training-orthopaedic-educational-supervisors/.

For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.

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JTO News and Updates

British Society for Surgery of the Hand Annual Meeting, Bath 2017 The meeting, hosted by Grey Giddins in Bath, opened with a free paper session covering topics such as fitness to drive following hand surgery, the use collagenase in Dupuytren’s contracture, the stability of PIPJ fractures and the recovery of elbow flexion following Obstetric Brachial Plexus Injuries.

This was followed by a symposium on CRPS, with Jeremy Field putting the surgical perspective, an update on clinical advances by Candy McCabe, a psychiatric and medico-legal view from Christopher Bass and insights on functional MRI from Professor Maihofner (Germany).

Grey Giddins addressing the delegates at the BSSH Spring Meeting

A symposium on the biomechanics of the wrist and hand followed in the afternoon with a review of the implications for arthroplasty in the wrist and digits. Professor David Ring (Texas) delivered the Harold Bolton memorial lecture on the psychological aspects of Hand surgery. Professor Blake closed the day talking on the critical role played by the surgeons and physicians of Bath in developing enlightenment medicine and founding the modern medical-scientific method. This was followed by a walking tour of Bath with dinner in the Pump Rooms. Friday opened with free papers and a session for investigators in the BSSH sponsored SWIFFT and DISC NIHR portfolio studies. There were thought provoking sessions on surgical errors, variation in practice and surgical bias with contributions from Grey Giddins, David Ring and James Wright. Leslie Hamilton

discussed the lessons to be learnt from cardiothoracic surgery. The Presidents of BAPRAS, David Ward, and the BOA, Ian Winson spoke on the challenges facing the profession, particularly from the perspective of trainees and junior surgeons. They also discussed the benefit of the BSSH continuing to work closely with its parent societies. The final afternoon included a review of the evidence in the treatment of Bennett’s fractures and the role of injections and surgery in carpal tunnel syndrome. The meeting closed with presentations on surgical techniques in thumb base arthritis, PIPJ arthroplasty and flexor tendon repair. The Autumn meeting will be held on the 9th and 10th November 2017 in Edinburgh.

CSOS Annual Meeting, Edinburgh 2017 The Combined Services Orthopaedic Society held their annual meeting at the Royal College of Surgeons, Edinburgh on 13th May. There was a good turnout with attendees, both former and current, from all three services. The instructional portion: ICSOS, organised by Surg Cdr Guyver, was on 12th May, at Redford Barracks, and focused on simulation techniques. The main meeting was organised by Surg Cdr Arthur. The morning sessions concentrated on both civilian and military trauma. The afternoon covered elective practice and research. Presentation standards were very high with thought-provoking discussions of such diverse topics as the Falklands conflict, the modelling of undervehicle explosions, prevention and treatment of heterotopic ossification and the readability of our patient information leaflets.

Delegates and speakers at the CSOS Meeting in May

Dr James Robson delivered a fascinating guest lecture on his work with the Scottish and Lions Rugby teams. Professor Briggs updated us, not only on the progress of the GIRFT initiative,

but also on the implementation of the Chavasse report and the progress towards veterans rehabilitation units. Col Standley L/RAMC delivered the state of the Nation Address.

Dinner was held on the Royal Yacht Britannia. Next year’s meeting will be on 10th-11th May with RCDM, Birmingham hosting.

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JTO News and Updates

BODS Meeting, Birmingham 2017 The British Orthopaedic Directors Society (BODS) met at the Royal Orthopaedic Hospital in Birmingham on the 19th May 2017. The meeting was very interactive with interesting discussions following on from presentations on a wide range of topics relevant to Clinical and Medical Directors. Jeremy Field spoke on his experience of training in mediation and then applying this in his workplace. Paul Carter led a discussion on

managing the job plans of consultants and the difficulties of negotiating appropriate recognition of work done in direct clinical care and supporting activities. Tim Briggs brought the participants up to date on the developments in the GIRFT programme and the impact this is having on orthopaedic practice. Phil Turner spoke about the objective evidence that could be used when negotiating with commissioners who

are applying increasingly draconian and damaging restrictions on criteria for referral into our units for surgical care. He stressed that the BOA Commissioning Guidelines are fully supported by NICE and NHSE. Simon Fleming, President of BOTA, then presented an update on the growing ‘Hammer it out’ campaign highlighting the unacceptable culture of undermining, bullying and harassment across the

Royal Orthopaedic Hospital, Birmingham

NHS and the steps to be taken to report and stop aberrant behaviour as well as support good practice.

BOOS Meeting, Newcastle 2017 The 2017 British Orthopaedic Oncology Society meeting was held in the pleasant surroundings of the education centre in Newcastle’s Royal Victoria Infirmary. The meeting provides a forum for research, education and the exchange of ideas. It was well supported by consultants, trainees, and industry. Professor Peter Ferguson of the Mount

Sinai Hospital, Toronto gave two excellent presentations: one reviewed his clinical experience and research into fractures after sarcoma treatment and the other shared insights into differences between the Canadian and UK systems for sarcoma care and training. Both were well received and prompted much discussion.

Delegates enjoying the BOOS Meeting in Newcastle

The quality of scientific presentations was very high. Three prizes were awarded: best podium presentation went to Dr Downie of NHS Tayside for her paper “A novel scoring system for predicting early mortality in patients with metastatic proximal femoral fractures”; the best poster was from Dr Kular of Newcastle University entitled “Accuracy of MRI in local staging

of myxofibrosarcoma”, and the best basic science presentation was from Mr Gourbault, a medical student at Newcastle University for his poster “Promising new target for treatment of human and canine sarcoma”. Other topics included review of the BOOS leadership fellowship, presented by Louise McCulloch, and the national research agenda. Conversations continued into the evening in the Wylam Brewery, over dinner at Northern Stage, and the next day when the local hosts took Peter and Mel Ferguson on a walk along Northumbria’s beautiful coastline. Next year‘s meeting is in Edinburgh, hosted by Sam Patton, and a meeting in Leiden is slated for 2018. Thanks to all who attended, the sponsors, Peter and Mel Ferguson and Echo Events who helped deliver an excellent meeting.

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JTO News and Updates

World Orthopaedic Concern UK 4th Annual Conference Since WOC-UK switched their main annual event from an extended executive meeting to a formal conference in 2014, it has been going from strength to strength. The theme of this year’s meeting was “Engagement from trainee to trainer”. It was set in the historic grounds of Wrightington hospital, where conference organiser Mr Tony Clayson is based.

(Clockwise) Organiser Tony Clayson introducing WOC Chairman Steve Mannion - Prof Jim Harrison being awarded his Arthur Eyre-Brook medal by Mr Mannion - Liz Newton doing a sterling job with the organisation

We attracted a distinguished line up of keynote speakers, including Professor Ged Byrne from Health Education England and Dame Sue Bailey DBE, Chair of the Academy of Medical Royal Colleges. They gave us an encouraging insight into the work that is being undertaken to promote overseas work, acknowledging the huge benefits to the NHS as an organisation and individually to the participant. Following this Professor Jim Harrison, from Chester, who has

11 years’ experience working in Malawi, where he has helped to revolutionise the delivery of orthopaedic care. He was awarded the Arthur Eyre-Brook medal in recognition of his global achievements. The programme for the rest of the day was varied, including free papers and country and trainee/ fellowship reports. Mr David Hillier won the best presentation prize for his work on a new fracture fixation assessment tool. Mr Clayson then wrapped up the day with a powerful account of his work with the Northwest Orthopaedic and Trauma Alliance for Africa (NOTAA), which he co-founded. With about 50 people attending and feedback exceeding our expectations, we consider this year’s event to have been a great success! We would like to thank Liz Newton for her skill and hard work in coordinating the whole event.

CAOS Meeting Over 250 filled Eurogress Aachen on 14th June to discuss recent developments at the yearly meeting of the International Society for Computer Assisted Orthopaedic Surgery. Current research in the areas of computercontrolled tumor-therapy, computer-assisted planning and the manufacture of patientspecific joint-implants using 3D-printing-technology sparked great interest in the attendees. It has also become apparent that digital networking and integrated clinical quality management have great potential in computerbased orthopaedic surgery. The conference-host and president of the international scientific society of CAOS was Professor Klaus Radermacher, who is the director of Medical Engineering

at the Helmholtz Institute for Biomedical Engineering, RWTH Aachen. He stated that CAOS2017 had unique potential as a result of the interdisciplinary discussions in workshops, conference as well as poster-discussions. The meeting also gave the attendees an insight into the most recent research and developments of this interdisciplinary area of science. The conference was supported by the European Orthopaedic Research Society (EORS), the German Spine Society, the Northern-German Association for Orthopaedic and Trauma Surgery and the German Society for Biomechanics. Next year’s CAOS meeting will be from 6th–9th June 2018 in Beijing, China.

Delegates enjoying the exhibition at the CAOS meeting

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JTO News and Updates

BESS Meeting, Coventry 2017 This year BESS travelled to Coventry, attracting 515 delegates to the Ricoh arena, home of the Wasps rugby team. We added an extra day to the meeting for an instructional course on arthritis of the shoulder and elbow. This attracted 150 delegates – a great success. The instructional course will now be run annually on the day before the meeting. There will be a rolling five-year syllabus. The meeting opened with the Allied Health Professional

symposium on ‘informing and enhancing our approach to upper limb rehabilitation’ with guest lecturers Gregory Cunningham, Chris Littlewood, Robert Letchford and Tamar Pincus. There was a scientific research symposium, which focused on ‘management of the young arthritic shoulder’. Lectures were given by Jonathan Rees, Joaquin Sanchez-Sotelo and John Sperling. There were also early morning masterclasses run by the local organising committee.

There were free papers and a ‘hot topic session’ on current medical practice. Our two guest speakers delivered thought provoking lectures: Luc Favard from France on ‘Shoulder arthroplasty’ and Bo Olsen from Denmark on ‘Registry data in arthroplasty of the shoulder and the elbow’. Several BESS funded fellowships and pump priming research grants were awarded along with prizes for the best papers. Mr Michael Watson,

one of four founding BESS members and a past president was made an honorary member. A conference dinner was held on the Wednesday evening in the arena. We would like to thank to our Coventry colleagues for hosting this conference and we now look forward to BESS 2018 in Glasgow.

BIOS Meeting, Cumbria 2017 The British Indian Orthopaedic Society (BIOS) held its 19th Annual Conference in Carlisle on Friday 14th and Saturday 15th July 2017.

Prof Arun Purushottaman, Design Scientist and Engineer, Aerospace, Remote and Rocket technologies

On the first day 80 delegates participated in a variety of interactive training workshops and free papers sessions. Patients were involved in creating the innovative Leadership programme and design engineers like eminent rocket scientist from India Prof Arun Purushottaman (pic) supported the collaborative work in the Design Technology workshop. There was an interactive video-streamed debate on medical tourism and participation by Umesh Prabhu and Matt Makin discussing the impact of health and social care devolution in the North West.

Peter Kay, representing the Royal College of Surgeons of England, and Ian Winson spoke to encourage an increase in collaborative training programmes and improving access to orthopaedic and trauma services. Prof Ram Prabhoo, President Indian Orthopaedic Association, explained the structure of the IOA and its preparedness for the future, emphasising the need for excellence in training and the importance of prevention and treatment in musculo-skeletal disease and injury. Prof Ramesh Sen then discussed the prevention of morbidity and mortality, by the better early management of major pelvic injuries in India and other developing communities throughout the world.

Day two saw 93 delegates including 24 trainees, hearing about the key challenges in collaborative training, the clinical management of trauma and early interventions for knee OA.

The conference dinner was graced by Her Worshipful Mayor of the City of Carlisle, Cllr Trish Lacey, who also took to the floor, enjoying the glamour of Bollywood dancing.

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19.10.16 08:54

RNOH EDUCATION The Royal National Orthopaedic Hospital has one of the largest CPD course portfolios in the NHS. We provide high quality learning across a range of specialties and professions working with musculo-skeletal injury and disease. The Stanmore FRCS Preparation Series

The RNOH FRCS (T&O) VIVA Course 21 Oct ‘17 Preparation in Basic Sciences for the FRCS (T&O) Mar ‘18 Preparation in Neuro-Urology for FRCS (Uro) Course 18-20 Apr ‘18 Preparation in Basic Sciences for the FRCS (T&O) Sep ‘18

The Stanmore Orthopaedic Series

Casting Techniques for Orthopaedic Surgeons Ex-Fix Essentials External Fixators Casting Techniques for Orthopaedic Surgeons ST3 (Orth) Interview Preparation Course RNOH/BOSA Current Concepts & Controversy in Ortho & Trauma 7th Cadaveric Knee Replacement Course Stanmore Spinal Course Complex Primary and Hip Revision

10 Nov ‘17 30 Nov-1 Dec ‘17 Feb ‘18 Feb ‘18 Mar’18 Jun ‘18 Jun ‘18 Nov ‘18

The Stanmore Paediatric Series

Childhood Hip Conditions The RNOH Ponseti Course 5th Vitamin D Conference Neonatal Hip Examination Course The RNOH Ponseti Course

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Advanced Life Support (ALS) Generic Instructors Course (GIC) Advanced Life Support (ALS) European Paediatric Advanced Life Support (EPALS) Advanced Life Support (ALS) Generic Instructors Course (GIC)

For further information and to register for a course go to: www.rnoh.nhs.uk/health-professionals/courses-conferences, email courses@rnoh.nhs.uk or call the Teaching Centre Team on 020 8909 5326

15 Sep ‘17 6 Nov ‘17 27 Nov ‘17 Feb ‘18 May ‘18 23-24 Sep ‘17 18-19 Nov ‘17 24-25 Mar ‘18 19-20 May ‘18 22-23 Sep ‘18 24-25 Nov ‘18

Volume 05 / Issue 03 / September 2017

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boa.ac.uk

JTO News and Updates

Joint Action Challenge Events We would like to congratulate Deiary Kader for participating and completing the RideLondon-Surrey 46 on Sunday 30th July. Also huge congratulations to Jonathan Compson and Rupert Wharton who successfully cycled the 100 mile event. Emily Farman, BOA Marketing and Communications Officer took part in the London 10k on Sunday 9th July. Well done to all of our participants and for raising tremendous donations for Joint Action. If you are interested in participating in our 2018 events (including the London Marathon) please contact jointaction@boa.ac.uk.

Deiary Kader completed the RideLondon-Surrey 46

Rupert Wharton successfully cycled the 100 mile event

Emily Farman completed the London 10k

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Summary of Indications for Use: EXOGEN is indicated for the non-invasive treatment of osseous defects (excluding vertebra and skull) that includes the treatment of delayed unions, non-unions†, stress fractures and joint fusion. EXOGEN is also indicated for the acceleration of fresh fracture heal time, repair following osteotomy, repair in bone transport procedures and repair in distraction osteogenesis procedures. There are no known contraindications for the EXOGEN device. Safety and effectiveness have not been established for individuals lacking skeletal maturity, pregnant or nursing women, patients with cardiac pacemakers, on fractures due to bone cancer, or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling, or at www.exogen.com. †

A non-union is considered to be established when the fracture site shows no visibly progressive signs of healing.

References: 1. Nolte PA, van der Krans A, Patka P, et al. Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma. 2001;51(4):693−703. 2. Schofer MD, Block JE, Aigner J, Schmelz A. Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskelet Disord. 2010;11(1):229. 3. Heckman JD, Ryaby JP, McCabe J, et al. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg [Am]. 1994;76(1):26−34. 4. Kristiansen TK, Ryaby JP, McCabe J, et al. Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study. J Bone Joint Surg [Am]. 1997;79(7):961−973. © 2016 Bioventus LLC Bioventus, the Bioventus logo, and EXOGEN are registered trademarks of Bioventus LLC. SMK-001795

Volume 05 / Issue 03 / September 2017

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JTO News and Updates

An Update on the Royal College of Surgeons of England Modernisation With the main College building shutting its doors for three years this month, work on Project 2020 has continued unabated to meet the deadline. The main college building will be out of use until the end of 2020. This will enable it to be transformed into a modern, light and flexible facility reflecting the changing nature of surgery in the 21st century; the RCS and its partners will move into the adjoining Nuffield Building.

In early 2017 the College received planning consent from Westminster City Council to part demolish and rebuild the current Barry Building. Since then internal building work has been underway in the Nuffield Building to temporarily accommodate the College and Specialist Associations during the Barry building works. The Technical Design stage of the building plan was completed in the early summer and all staff and tenants will be moved by the end of August. This move has created opportunities for closer working within the College, especially with the

Caption Competition Thank you to those who entered the last issueâ&#x20AC;&#x2122;s caption competition (photo on left). Congratulations to Neil Wicks whose caption was: I said move the Image Intensifier distally! On the right is our latest photo of BOA Past President, Tim Wilton at the Titanic Museum. For your chance to win a ÂŁ20 voucher, simply email your caption to jto@boa.ac.uk with the subject: Caption Competition. Please send your photos for future competitions also to this email address (no larger than 5MB). Please submit your caption by 29th September 2017.

Specialty Associations, all of whom have been very understanding considering the pressures and compromises that have had to be made. It is envisaged that moving forwards closer working will enable the College and Specialist Associations to better collaborate around surgical training, standards and care, whilst also providing services to our members and fellows. During the three years in the Nuffield Building, we will continue to support members and fellows, care for our historic and heritage collections, as well as providing courses and exams. We are also planning our return to the new building in 2020, and in particular allowing the Specialist Associations to fulfil their future vision. This will allow us to place the College at the centre of advances in surgical care.

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Volume 05 / Issue 03 / September 2017

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boa.ac.uk

JTO News and Updates

President’s Update: Annual Report 2016 Ian Winson, BOA President Tim Wilton, BOA Immediate Past President 2016 was a tumultuous year for both the UK and the NHS – and the BOA has been in the thick of it. We have reassured our European colleagues that BREXIT will not involve any withdrawal on our part from the broader musculoskeletal agenda in Europe, while our trauma community continues to review and adjust its terrorist response capability in the light of events overseas. We have also actively and repeatedly pressed the case for joint replacement patients to ensure that they are not disproportionately disadvantaged by a plethora of savings measures throughout a cash-strapped NHS. We stood foursquare behind the Junior Doctors in their negotiations with the Department of Health, while deploring the circumstances that led to industrial action and the subsequent imposition of the contract. Conscious that the representation of women in our specialty could and should be better, we embarked on a programme of affirmative action to redress the balance. Our report that follows cannot possibly touch on every aspect of our activity: we have highlighted the principal elements.

Ian Winson

Tim Wilton

The year started with the launch of our leadership guidance to implement the Getting It Right First Time (GIRFT) programme for trauma and orthopaedics (T&O) in England. It is important to remember that while GIRFT

has strong political backing, it is nonetheless an enabling, data driven process designed to support evidence based continuous quality improvement in our clinical practice. The real impetus to drive quality improvement is necessarily led by the profession itself, with BOA members at the forefront, fully supported by their professional body. As with any innovative approach, there have been some teething problems with the data and its presentation: these have been fed back to us and we have worked extensively with the GIRFT team in NHS Improvement (NHSI) to ensure their rectification so that essential momentum may be sustained by surgeons at the front line. This experience will be invaluable as similar implementation programmes – tailored to the devolved nations’ particular needs - are rolled out in Scotland, Wales and Northern Ireland. For elective care, we and our affiliated Specialist Societies have also continued to build on our understanding of clinical outcome variance analysis, working closely with colleagues in the National Joint Registry (NJR). This has reinforced our conviction that not only is the publication of individual surgeon outcomes flawed on grounds of insufficiently robust data that is of parlous use to patients; but also the whole outlier lexicon has the potential to act as a

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barrier to quality improvement. The unduly punitive tone of outlier phraseology can be counter-productive for many surgeons; it tends to instil a sense of denial, rather than fostering the essential insight that lies at the heart of a supportive or just professional culture. These convictions and human factor observations have been further reinforced during our work to support the emerging registries within our profession through the creation of the Trauma and Orthopaedic Registries Unifying Structure (TORUS): while we have made commendable progress with the TORUS, it has not been without significant effort to assuage peoples’ legitimate concerns that the data would be used to castigate them rather than enhance quality improvement. Accordingly, we and the NJR have represented robustly to NHS England at the highest level the benefits of unit outcome reporting and a team based approach, and have proposed an alternative assurance framework based on a just culture supported by a new system of BOA elective care quality reviews. We judge these reviews are best placed to support effective regulation: they build on our parallel experience in trauma with the highly regarded BOA hip fracture service reviews. We fully appreciate that any change to unit based reporting may take time and political will to implement, nevertheless we are encouraged that NHS England has been listening to and acting upon our advice, with the name change to the Clinical (rather than Consultant) Outcome Programme, an emphasis on teams for any new national audits, and a change of focus from ‘rooting out poor performance’ to ‘celebrating success’. There is one further area where we have had particularly extensive engagement with

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the NHS, and that is the Tariff which is set centrally and used by CCGs to reimburse hospital providers for the procedures they commission. Throughout the first half of 2016 our Expert Working Group (EWG) collaborated closely with NHS Improvement to achieve a workable T&O tariff for the ensuing two financial years. The pace of this work was intense, often encroached on bank holiday weekends, and resulted at the end of the summer in a viable solution that would have ensured a sustainable funding outcome. To our consternation the entire contribution from our EWG was disregarded when the statutory tariff consultation was published by NHSI in the Autumn with a proposed a 13.5% reduction for T&O. Naturally we responded to the consultation in the strongest terms. Moreover, in the absence of any meaningful explanation for this behaviour we wrote to the Chief Executive of NHSI setting out clearly the potential implications for orthopaedic patients and seeking further dialogue. In the meantime, our broader professional practice work to promote quality improvement has continued apace with further auditable standards for trauma, new elective care standards, revised commissioning guides, further developments to the Beyond Compliance and Orthopaedic Data Evaluation Panel services, close engagement with the nascent Private Healthcare Information Network (PHIN), and sustained contributions to the national initiatives to establish a MSK Health Questionnaire, MSK indicator sets, multidisciplinary MSK team competency frameworks, and MSK networks in various guises. Turning to training and education, we delivered a highly acclaimed programme of continuous professional development at our Belfast Congress, with a particular focus on clinical leadership

and engagement, in addition to our customary revalidation instructional sessions. The latter are master minded by our affiliated Specialist Societies to ensure that all T&O surgeons are able to keep up to date in the generality of their profession. The Congress partnership with the Specialist Societies is highly effective and their contribution hugely appreciated. Our 2016 Instructional Course for surgeons in training was fully subscribed and in light of that we increased the numbers for the 2017 course (which was also full): here the format continues to be one of interactive case based discussion, and we are enormously grateful to the faculty who give freely of their time. Wikipaedics, our e-learning platform based on Moodle, continues to develop with the strong support of our affiliated Specialist Societies: in response to trainee focus groups the emphasis has shifted to one of higher order learning delivered through a variety of different media to support FRCS revision. As Wikipaedics will be open access the product has potentially enormous reach and provides us with an opportunity, through the integration into Moodle of our UK In-Training Examination, to extend our membership offer internationally: the South African Orthopaedic Association has already subscribed to UKITE, with others set to follow. The key to future success for Wikipaedics lies in attracting significant sponsorship from industry, and potentially the identification of a publishing partner with a well developed digital infrastructure. BOA Travelling Fellowships remain in strong demand, as does our Clinical Leaders Programme, and we were pleased to contribute to the Chinese and Indian Association Congresses, as well as the Carousel’s Combined Orthopaedic Association Congress.

Having invested significantly in the British Orthopaedic Surgical Research Centre (BOSRC) in York we are delighted to report a significant return: the profile and extent of T&O research have never been higher and continue to rise, enabled by further investment in priority setting partnerships with substantial patient and public involvement that catch the eye of major funders. As a consequence the T&O research agenda now has a very much more professional feel to it and real teeth. We take this opportunity to express our enormous gratitude to all those individuals whose donations and legacies have supported our members’ research work: the benefits to future generations of patients and surgeons are inestimable. Lastly, our Benevolent Fund has had a busy year, suffice it to say that the level of activity underlines the importance of this particular charitable object. In summary, 2016 was especially busy and we see no prospect of any let up during 2017. As a charity we fully embrace close collaboration with the NHS, provided it is to the public benefit. The result should be enhanced and better value care for our patients, while supporting surgeons. We say ‘should be’ because during 2016 that was not always the case: let us hope that the Tariff experience was a one off and there is no future recurrence. Our work is intense yet rewarding. It would not be possible without the unstinting support of our clinical volunteers, Patient Liaison Group, affiliated Specialist Societies and professional staff: we pay tribute to their enormous dedication and contribution. n

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JTO News and Updates

The American British Canadian Fellowship 2017 The ABC Traveling Fellowship is a biennial exchange between the English Speaking Orthopaedic Societies. It began in 1948 to enhance collaboration between British and North American Surgeons. Now, in the even-numbered years, British, Australian, New Zealand, and South African orthopaedic surgeons, who have been chosen by their national societies, visit academic centers in the United States and Canada. In the odd-numbered years, the American and Canadian surgeons travel to the United Kingdom and either South Africa, or Australia and New Zealand. In this way, the fellowship tries to stay true to its original goal of disseminating knowledge, fostering collaboration, and encouraging leadership. Our time in the United Kingdom helped us better understand Mark Twain’s quote that “nothing so liberalises a man and expands the kindly instincts that nature put in him as travel and contact with many kinds of people.” Our time in the UK allowed us broad exposure to the hard-working individuals who compose the National Health Service, the research engines which are being used to produce large-scale prospective randomised clinical trials, and the burgeoning groups of scientists who are working to generate translational research. Most importantly we all made new acquaintances, which will allow us to collaborate in the future. Our journey started in London with Hazel Choules and Deborah Eastwood (ABC 1994) who gave us an overview of our itinerary in the lounge of the Grange Hotel. The next day, we toured

Imperial College with Prof Justin Cobb. Following this exciting tour, we met Prof Fares Haddad (ABC 2004) for lunch and a meeting with the Bone and Joint Journal Board. The next day, we toured University College London Hospitals, hosted by Sam Oussedik (ABC 2016). On the following day Jonathan Miles (ABC 2016) and John Skinner (ABC 2004) led us on a tour of the Tower of London, Westminster Abbey, and lastly the Royal National Orthopaedic Hospital, Stanmore. Unfortunately, we also got a taste of London traffic, which abbreviated, but did not diminish, our time with Tim Briggs (ABC 1998). We ended our time in London with the black tie BOA annual Dinner. Matt Costa (ABC 2010) and Andy Carr (ABC 1998) were our hosts in Oxford. We were introduced to the UK trauma network. Prof Keith Willett, the architect of the current system of orthopaedic trauma care in the UK, provided an insightful lecture on past and present trauma care. We toured the awesome clinical and research facilities at the John Radcliffe Hospital in Oxford, in addition to the

historical university campus. We “punted” – learning that this is a slow canoeing-like activity, not a way of converting field position on 4th down. We were exposed to a well-organised, well-funded, well-maintained prospective trials and outcomes research machine. We attended a gala dinner at Balliol College with numerous other ABC alumni. From Oxford, we transferred to Cambridge where Vikas Khanduja and Prof Andy McCaskie were our hosts. There, we attended trauma rounds, toured the hospital, and saw the new

translational research lab which opened a week after we left. We were also exposed to Prof McCaskie’s bioengineering research and the laboratory where he works. We made the most of the Bank Holiday by touring the Cambridge campus and further punting! Our stay in Cambridge finished with a formal dinner at Queen’s College, which dates to 1448. Next we flew to Edinburgh where Prof Hamish Simpson (ABC 1996) entertained us at home, with an excellent curry prepared by his wife, Helen. We were privileged to enjoy drinks at the officer’s mess, Edinburgh Castle, courtesy of Surgeon Commander Calam Arthur. To help compensate for the food and drink, we hiked Arthur’s Seat and marvelled at the beautiful views of the city below. We met numerous ABC alumni socially and/or at a very enriching academic day in which both sides presented their research. Our brief but energetic time in Edinburgh ended with a black tie dinner at the New Club.

(L-R) Joseph Hsu, Jonathan Braman, Eric Strauss, David Sheps, Brett Freedman, Nicholas Bernthal, Wade Gofton

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Returning to England, we made our way to Wrightington - Charnley’s home. Our stay there was memorable for many reasons. Not only is it the birthplace of cemented, low-friction arthroplasty, but we arrived in time for their Gold Medal academic session. Dr. Bodo Purbach, a Charnley disciple, shared many radiographs of Charnley’s cemented total hips, some dating back 50-years. He also took us on a tour of the Charnley Museum. Martyn Porter (ABC 1994) took us to a premier league soccer match, Burnley against West Bromwich Albion. We were feeling the cold by this point, and left the match with more Burnley

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gear than the most ardent fan might own. We next headed up to the Lake District and stayed at the manorial home of Peter Kay (ABC 1998) and his wife, Thelma, for the weekend. We relaxed, ate, and took a ‘leisurely’ walk along Striding Edge at Helvellyn. We survived the hike, some better than others, and were all ‘refreshed’ by the experience. The sticky toffee pudding was well earned that night. Ajay Malviya (ABC 2016), Michael Reed (ABC 2012) and Will Eardly (ABC 2016) looked after us in Northumbria. The academic session was excellent, and our accommodation was sublime.

Paul Partington hosted a dinner and bonfire at his beautifully renovated home. We enjoyed some rare free time by shooting sporting clays at Slaley Hall. We travelled to York to learn about their Trials Unit and see large multicenter prospective clinical research in action. Our host, Amar Rangan (ABC 2010), discussed the results of the pivotal Level 1 trials that have been recently conducted across the UK. This led to a spirited discussion on the impact these trials have on National Health Service policy, with an eye towards how they will also impact healthcare decisions in North America.

A free day in London and our departure from the UK was perfectly timed, after a cyber attack crippled much of the NHS. We were happy to leave the ransomware behind and travel to South Africa. Our time in the UK achieved all that the ABC Traveling Fellowship intended. It was an opportunity to learn, to share, and to make new acquaintances. It broadened our horizons and increased knowledge. We would like to thank the American Orthopaedic Association, the British Orthopaedic Association, and the Bone and Joint Journal for their generosity. n

ORGANISED BY THE ORTHOPAEDICS SECTION

Digital orthopaedics:

Future orthopaedic surgeons conference 2017

Artificial intelligence and big data Now running for it’s 3rd year, this meeting aims to bridge the worlds of clinical orthopedics (from wellness to trauma) and digital health (from big data to augmented reality). By the end of this meeting delegates will understand the purpose of catalysing the adoption of technology in the vertical of musculoskeletal care.

The Future orthopaedic surgeons conference (FOSC) is an international trauma and orthopaedic surgery conference aimed solely at medical students and junior doctors. Now in it’s ninth year at the Royal Society of Medicine, FOSC continues to bring the latest updates on orthopaedic training and selection and cutting edge practical workshops.

Prices start from £15 Find out more and register today at: www.rsm.ac.uk/events/ork01

Prices start from £40 Find out more and register today at: www.rsm.ac.uk/events/ork03

Venue Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE

Wednesday 15 November 2017 Half Day - 1.30pm to 5.30pm CPD: Applied for

Saturday 9 December 2017 CPD: Applied for

Volume 05 / Issue 03 / September 2017

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boa.ac.uk

JTO News and Updates

BOA Membership Update BOA Congress 2017 congress.boa.ac.uk

19th-22nd September, ACC Liverpool, Quality & Innovation We are excited to welcome you to Liverpool, over 1,900 surgeons, trainees and medical students have registered for the Congress. We are pleased to have in attendance over 80 exhibitors at the Congress, many of which will be joining us for the first time. This is set to be our biggest Congress to date and we are delighted you are able to join us. The theme for this year’s Congress is ‘Quality and Innovation’ and we have built an exciting programme which underpins this.

BOA CONGRESS 2017 19-22 September - ACC Liverpool Quality & Innovation congress.boa.ac.uk #BOAAC

Membership update Our membership has grown by over 7% in the past twelve months and we are keen to increase this continually year on year. To date we have over 4,700 members. For more information on the benefits and subscription categories please visit the BOA website: www.boa.ac.uk/membership/categories-and-subscriptions.

Join our 10,000 followers on Twitter! Connect with us on Twitter, LinkedIn and Facebook to keep up to date with the latest news and updates including our events, training and education projects and our engagement work. Twitter: @BritOrthopaedic LinkedIn: British Orthopaedic Association Facebook: British Orthopaedic Association @BritOrthopaedic

We look forward to welcoming our guest speakers to the Congress. The Presidential Guest Lecture will be delivered by Jan Louwerens, who founded and chaired the Dutch Orthopaedic Foot and Ankle Association. The Robert Jones Lecture will be delivered by Professor Chris Moran, Professor in Orthopaedic Trauma Surgery at Nottingham University Hospital and is National Clinical Director for Trauma for NHS England. Phil Hammond, an NHS Doctor, campaigner and health writer will be delivering the Howard Steel Lecture. We are also delighted to confirm that the Carousel group, the Presidents of orthopaedic associations around the world, will discuss whether the rationing of Musculoskeletal Care is logical. Don’t forget to visit the BOA stand (29) while walking through the exhibition hall and meet the BOA team!

BOA INSTRUCTIONAL COURSE 2018 6th-7th January • Macdonald Hotel, Manchester

REGISTRATION NOW OPEN! boa.ac.uk/events/instructional-course

The BOA’s Instructional Course is an outstanding opportunity for trainees not only to gain a number of Case Based Discussions (CBDs) in a range of topics but also to network and attend lectures delivered by expert clinicians.

David Limb, Ananda Nanu, Nigel Rossiter and Hiro Tanaka will be delivering the plenary lectures at the Instructional Course. For the full list of conﬁrmed faculty please visit: boa.ac.uk/events/instructional-course.

The Case Based Discussions (CBDs) for 2018 will include: Foot and Ankle, Pelvic and Acetabular, Spine, Sarcoma and Trauma.

For further information please visit: boa.ac.uk/events/instructional-course. If you have any questions regarding the course please contact: policy@boa.ac.uk.

@BritOrthopaedic #BOAIC

British Orthopaedic Association

BritOrthopaedic

Wisepress Book of the Quarter Rothman Institute Manual of Total Joint Arthroplasty: Protocol-Based Care Author: William J. Hozack ISBN: 9789386261052 Date published: 1st Mar 2017 Price: £72.00 BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code. This book is a complete guide to total joint arthroplasty for orthopaedic surgeons presented as a collection of key protocols for surgery. Divided into four sections, the text begins with preoperative considerations, covering patient evaluation, clinical examination, indications, and implant selection. The following section provides step by step guidance on the complete range of arthroplasty techniques and associated procedures. Section three covers postoperative management such as wound care, transfusions, physical therapy, medication, and much more. The final chapters in the book discuss the management of numerous potential complications. Edited by an internationally recognised team of experts, led by Javad Parvizi from the renowned Rothman Institute in Philadelphia, this comprehensive guide is enhanced by surgical images and diagrams to assist learning.

Save the date!

BOA Annual Congress 2018 25th-28th September, ICC Birmingham

Join us in Birmingham next September to celebrate the BOA’s 100 year anniversary! We are delighted to be hosting the BOA’s centenary Congress at the ICC Birmingham. The programme will be a dedication to the growth and value of the BOA since 1918. Keep an eye on the Congress website for abstract submission information and further details of the programme - congress.boa.ac.uk.

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JTO News and Updates

Conference Listing: BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk

BASK (British Association for Surgery of the Knee) www.baskonline.com

SBPR (Society for Back Pain Research)

BRITSPINE

1-3 November 2017, Sheffield

www.sbpr.info 2-3 November 2017, Northampton

BTS (British Trauma Society)

20-21 March 2018, Leicester

www.spinesurgeons.ac.uk 21-23 March 2018, Leeds

BSSH (British Society for Surgery of the Hand)

www.bts-org.co.uk 8-9 November 2017, Sheffield

www.bssh.ac.uk 3-4 May 2018, Cardiff

BOTA (British Orthopaedic Trainees Association)

CSOS (Combined Services Orthopaedic Society)

www.bota.org.uk 15-16 November 2017, Manchester

www.csos.co.uk 10-11 May 2018, Birmingham

BSS (British Scoliosis Society)

EFORT (European Federation of National Associations of Orthopaedics and Traumatology)

www.britscoliosissoc.org.uk 29 November-1 December 2017, Birmingham

BOSTAA (British Orthopaedic Sports Trauma & Arthroscopy Association) www.bostaa.ac.uk 6 December 2017, London

OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 11-12 January 2018, Bristol

www.efort.org 30 May-1 June 2018, Barcelona

BOOS (British Orthopaedic Oncology Society)

www.boos.org.uk 8 June 2018, Edinburgh

BESS (British Elbow and Shoulder Society)

www.bess.org.uk 20-22 June 2018, Glasgow

BSCOS (British Society for Childrenâ&#x20AC;&#x2122;s Orthopaedic Surgery) www.bscos.org.uk 8-9 March 2018, Crewe

BHS (British Hip Society)

www.britishhipsociety.com 14-16 March 2018, Derby

BLRS (British Limb Reconstruction Society)

www.blrs.org.uk 15-16 March 2018, Southampton

BOA (British Orthopaedic Association)

www.boa.ac.uk 25-28 September 2018, ICC Birmingham

3º physiological joint line

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1. Zingde SM, Mueller J, Komistek RD, MacNaughton JM, Anderle MR, Mauhfouz MR. In vivo comparison of tka kinematics for subjects having a PS, PCR, or Bi-Cruciate Stabilizing design. Orthopedic Research Society. 2009; Paper No. 2067. 2. Catani F, Ensini A, Belvedere C, Feliciangeli A, Benedetti MG, Leardini A, Giannini S. In vivo kinematics and kinetics of a bi-cruciate substituting total knee arthroplasty: a combined fluoroscopic and gait analysis study. J Orthop Res. 2009 Dec;27(12):1569-75. 3. Arbuthnot JE, Brink RB. Assessment of the antero-posterior and rotational stability of the anterior cruciate ligament analogue in a guided motion bi-cruciate stabilized total knee arthroplasty. J Med Eng Technol. 2009;33(8):610-5.

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An update on the British Orthopaedic Surgery Research Centre (BOSRC) Amar Rangan I was appointed to Chair the BOA Research Committee five years ago, tasked with developing a committee structure and driving quality improvement in our research activity. We now have an established committee structure with succession planning and terms of reference. I am due to complete my term as Chair of the Research Committee and will hand over this responsibility to Matt Costa after the BOA Congress this year. It is therefore timely to reflect on the progress we have made so far, particularly our hugely successful venture in driving clinical effectiveness research in Trauma and Orthopaedics (T&O).

Amar Rangan

We have limited funds within Joint Action, which are insufficient in the current day to fully support a high quality research project. Historically, small grants were awarded to support studies, many of which did not complete and some did not even get off the ground! This was no longer sustainable, and we felt our limited research funds should be used more effectively in a ‘pump priming’ fashion to attract substantial external funding to support T&O research. The Research Committeee agreed that using these funds to secure methodological support for high quality research applications would be the best way forward.

The BOA Orthopaedic Surgery Research Centre (BOSRC) was commissioned via open competition, with the York Trials Unit being awarded the BOSRC contract. This has led to wide reaching benefits, with the BOSRC supporting new and established surgeon researchers in submitting high quality research grant applications. The surgeons they have worked with came from allover, including Bristol, Leicester, Hull, South Tees, Peterborough and London. When orthopaedic surgeon coapplicants are also included the spread is even greater. So far, nine large-scale clinical projects

have been commissioned, attracting substantial funding to clinical research in T&O. For a modest £180,000 of ‘investment’ in the BOSRC over the first three years, we have attracted over £7 Million into T&O research, mainly via commissioned projects from the National Institute for Health Research (NIHR). When we include the support provided by the NIHR Clinical Research Networks (NIHR-CRN), the research funding coming into T&O is considerably higher. The BOSRC is also supporting our trainees in the gaining of higher degrees, with three T&O trainees currently out of programme pursuing their MD / PhD at York. Going forward, the BOSRC aims to deliver two new clinical trials per year; develop at least two new Chief Investigators per year, supporting them with grant applications and work with approximately 10 new Principal Investigators per year. There is also a plan to deliver important educational activity, including a two-day annual workshop on undertaking trials in T&O; support the BOA, specialist society meetings and trainee network events to promote and educate on surgical trials; and undertake social media activities targeted mainly at trainees to promote knowledge about research methods. This

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is an ambitious strategy, but will be of huge benefit to the BOA and the T&O community generally. There are much wider benefits from this strategy. As most commissioned studies are multi-centre UK-wide projects, they have engaged a growing number of our colleagues as Collaborators/Principal Investigators as well as hospitals as recruiting centres. There is clear emerging evidence that mere participation of a hospital in research improves the patient experience and outcomes. The research support via the NIHR-

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CRN by provision of research nurses to help with recruitment to clinical trials is helping participating hospitals build their research infrastructure. The growing international recognition that the UK is leading the way with high quality clinical trials in T&O is endorsement of our strategy. The BOA and BOSRC are grateful to the BOA members who continue to support Joint Action. Hopefully as the benefits of our new strategy become clearer, more colleagues will support our research agenda by opting and donating to Joint Action.

Finally, I would like to express my gratitude to members of the Research Committee (past and present), and the BOA staff who have supported me during my Chairmanship. Together we have achieved much in the last five years, which hopefully has laid the foundation for growing T&O clinical research excellence, and thus enhancing our global presence. It is my privilege to have contributed to the BOA research scene at this crucial and exciting time - the future certainly looks bright indeed!

Amar Rangan is Professor of Orthopaedic Surgery at the Department of Health Sciences, University of York; and at Faculty of Medical Sciences and NDORMS, University of Oxford. He leads a programme of clinical effectiveness research, particularly multicentre clinical trials. He maintains his clinical base in Middlesbrough as a specialist shoulder surgeon.

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Winner of the 2017 Robert Jones Medal and Association Prize Nick A. Smith The Robert Jones Medal and Association Prize is an annual essay writing competition on topics of orthopaedic interest, and in memory of Sir Robert Jones. It is awarded by the President of the British Orthopaedic Association at the Annual Congress.

Nick A. Smith

Who was Sir Robert Jones?

Why I applied

Born in 1858, Sir Robert Jones was a surgical pioneer and is considered by many to be the father of modern orthopaedics1. He published numerous books and papers on both deformities and fractures, and taught surgeons from across the world. He was instrumental in using x-rays for the diagnosis and treatment of orthopaedic conditions; the ‘Jones fracture’ of the fifth metatarsal is named after him. He was also a strong advocate for the use of immobilization in the treatment of fractures, which went against the vogue at the time. Arguably, his main contribution was to develop orthopaedics into a mainstream specialty in its own right. Prior to him, it was an offshoot of general surgery and mostly limited to the management of paediatric deformity. In 1918, Robert Jones instigated the foundation of the British Orthopaedic Association1.

I am currently a specialty registrar (ST7) in the West Midlands, having done most of my training at University Hospitals Coventry and Warwickshire. During this time I have been exposed to high quality research and researchers. Professor Matt Costa, who is himself a previous winner of the Robert Jones Medal, is a pioneer of evidence based medicine and in particular, randomised controlled trials in orthopaedics. He has been instrumental in my research training and my appetite for evidence based answers in orthopaedics. My entry to the competition was entitled, “Meniscectomy in a young patient: is meniscal allograft transplantation the answer?” It discusses the historical treatment of meniscal pathology and advances in understanding through to present day management and ideas for

the future. I used research from my PhD to provide the basis for discussion, as the competition lends itself well to having done a body of research in a specific field. The management of meniscal pathology has dramatically altered over the last century, as the consequences of meniscal loss have been better understood. The meniscus is a very effective load distributor and meniscectomy dramatically decreases total contact area whilst increasing peak contact pressures. It is now well known that meniscal loss results in a high risk of symptomatic osteoarthritis, and therefore attempts should be made to preserve as much functional meniscus as possible. It has been shown that meniscal repair results in a 20 to 50% reduction in the risk of symptomatic knee osteoarthritis compared to partial meniscectomy2. Despite this, it is not always possible to preserve a torn meniscus and some young patients end up with almost total meniscal loss. Meniscal allograft transplantation is performed in young patients with a symptomatic meniscal deficient knee compartment, otherwise known as ‘postmeniscectomy syndrome’. These patients invariably have some degenerative change of the joint. Whilst meniscal allograft transplantation is performed for symptomatic relief, it is possible that it also reduces the

development of osteoarthritis. My primary aim over the last few years was to determine whether meniscal allograft transplantation is more effective at improving symptoms than non-operative treatments, and I have performed a pilot for a full randomised controlled trial. My secondary aim was to establish whether meniscal allograft transplantation reduces the risk of the meniscus deficient knee developing osteoarthritis. My research contributed to the evidence that meniscal allograft transplantation is effective at improving pain and function. However, evidence that it can alter the natural history of joint degeneration is still limited and further studies are necessary

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before this question can be definitively answered.

Why others should apply The competition gives an opportunity for people to write about an area of orthopaedics that they are interested in. It is easier to write about a topic that you have previously done some research in, but this is certainly not a prerequisite. The opportunities to write in essay form are relatively limited in medicine and this competition gives you more freedom to write about a topic than you would otherwise have, for example, in academic papers.

Finally, Sir Robert Jones was a true pioneer and all of us working in the field of orthopaedics owe much to his legacy. It is therefore a great honour to win the prize and in a small way be associated with his name. It may even inspire you to become a pioneer of modern orthopaedics yourself. n Nick A. Smith is a specialty trainee (ST7) in trauma and orthopaedics on the West Midlands (Warwick) training programme. His clinical and academic interest is in knee and sports surgery, with numerous publications in this field. He obtained Arthritis Research UK Fellowship funding and then completed a PhD in 2016.

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References 1. Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malaysian orthopaedic journal 2014; 8(3): 37-41. 2. Englund M, Turkiewicz A, Bergkvist D, Meuman P, Persson F. The Risk of Symptomatic Knee Osteoarthritis after Arthroscopic Meniscus Repair Vs Partial Meniscectomy Vs the General Population. ACR/ARHP Annual Meeting; 2016: Arthritis Rheumatol; 2016.

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Who needs a logbook? David Large Since the GMC introduced its framework for appraisal and revalidation in 2011, doctors have been encouraged to reflect both on their practice and the supporting information that they gather about their practice. Should that supporting information for surgeons include a surgical logbook?

It seems obvious that it should, although I understand that not all consultants are asked for a logbook at their interview. Furthermore many of those who are, rely on theatre Information Systems to provide data on the scope and volume of their practice. This may be the reason that the numbers of discrete consultant users of the intercollegiate e-logbook is slowly declining. While it may be easy to use institutional systems, I would caution against relying on them. The data is frequently entered by nursing staff who

David Large

have little interest in its accuracy. For example in my practice the system frequently records me as doing a procedure, when in fact I have been supervising a trainee. I have also seen hospital theatre records which suggested, and I am quite sure he was not, that a particular orthopaedic surgeon was performing extraction of wisdom teeth! These records are frequently based on OPCS 4 codes which may be of statistical use, but are not a good basis for logbooks. For example, there are 42 different OPCS codes for hip or revision hip replacement, described in such impenetrable terminology as ‘unspecified…’, ‘conversion to…’ and ‘attention to…’. There is a huge and unnecessary complexity in these codes, which can only lead to errors and inaccuracies. Compare that to the ten ‘plain English’ codes for primary or revision total hip replacement used by the e-logbook. Furthermore, an appraisal interview should cover the entire scope of one’s practice. Many of us will work in more than one hospital each using its own information system. This requires the collation of the data in to a single logbook from several different systems. This is extremely tedious and use of the e-logbook avoids this difficulty.

While I am sure that many abandon the chore of keeping a logbook upon becoming a consultant as ‘something that they can do without’, in fact, maintaining a logbook becomes easier when you become a consultant, as you can build a large part by validating the operations undertaken by the trainees working with you. I am the first to admit that the current processes and software for validating trainee operations

Figure 1: e-logbook

are somewhat tedious, it does take less time than entering the cases yourself. Hopefully in the current redevelopment of the logbook, which will see it better integrated with ISCP, the process will become easier. I would therefore commend to you the continued use of the intercollegiate e-logbook as a consultant. The data is accurate, it can cover your whole practice, no matter how many hospitals you work in, and the reports are specifically designed to provide a detailed and readable picture of the scope and volume of your experience (Figure 1). n David Large has been a Consultant Orthopaedic Surgeon at Ayr Hospital since 1992. He is Honorary Clinical Associate Professor at the University of Glasgow and Chairman of the SAC in Trauma and Orthopaedics for the UK and Ireland.

BRITISH LIMB RECONSTRUCTION SOCIETY MEETING March 15-16 2018

CALL FOR PAPERS: Closing date 30 Nov 2017 Southampton is proud to host BLRS 2018 An exciting academic programme includes sessions on Biologics in Limb Reconstruction, Current Concepts, Gait Analysis, 3D Custom Printed Jigs, deformity planning as well as techniques to reduce or eliminate frame time. Dr Robert Rozbruch is amongst other international and national speakers. A dedicated session run by scrub staff on pre-building ring blocks/frames significantly shortening operative time will be part of the AHP programme. A full physiotherapist/ Theatre/Nurse Specialist is planned. A spectacular dinner has been arranged. Street food reception will precede the main sit down event with courses highlighting food from Amritsar to Lahore. Partners are very welcome. The meeting will be at The Hilton Ageas Bowl, a newly built facility with views of the cricket pitch and a fantastic Spa facility. Discounted packages for the Spa for attending partners have been arranged. Tickets are available through EventBrite

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JTO Features

SAC Agenda Mark Bowditch The BOA welcomes a new Chair to the Trauma and Orthopaedics SAC, Mark Bowditch, who outlines the work and challenges over the next three years.

Mark Bowditch

What is the SAC?

What is it responsible for?

The T&O SAC (Specialty Advisory Committee) is an advisory body working within the JCST (www.jcst.org), on behalf of the four surgical colleges (UK and Republic of Ireland), on all matters concerning T&O surgical training. It works closely with the BOA, BOTA and HEE.

The SAC’s remit is wide and varies to a degree across the five nations of the United Kingdom and Ireland. The remit covers:

The committee

l Standard setting, assessment/

It consists of 25 Liaison members (LMs), all practising orthopaedic surgeons with a strong training background, for example as a Training Programme Directors (TPDs). In addition, there is representation from the BOA, ISB exam board, HEE Lead Dean and BOTA. LM’s are appointed for 5-year term by BOA and Colleges. The SAC meets formally three to four times per year. It also has numerous subgroups www.jcst.org/committees/ specialty-advisory-committeessacs-1/trauma-orthopaedicsurgery-sac-members.

l The curriculum, training

structure, recruitment and selection process.

l Quality assurance and

enhancement, providing externality for training programmes. recommendations for Certification.

l Education, simulation,

opportunity and the culture of training.

Recruitment, workforce planning and selection into training The SAC and the BOA have contributed significantly to workforce planning. We have been successful in maintaining the case for recruitment numbers, perhaps more so than other specialties. Application ratios for training posts have remained

competitive; although Surgery and T&O are becoming less attractive with ratios falling below 2:1. The message is clear - we need to attract the attention of medical students and foundation doctors if we are to recruit the best candidates. Interestingly, the ratios of ST1’s applying for runthrough training in Scotland is much better; 11:1 – Maybe there is something about capturing the interest early? The SAC is looking at the other specialties pilots in Improved Surgical Training projects, some of which involve earlier recruitment and run through. We certainly don’t wish to be left behind, while others pick off the best candidates. The National ST3 selection process continues to mature under the leadership of James Hunter. We are confident that the process is fair and transparent and we are selecting the best candidates. Thanks to all of you who get involved, it would not happen without your input.

Curriculum Every three years the training curriculum is updated for the GMC. The next update is in 2018 and requires many GMC led changes around ‘entrustable professional activities’. The updated curriculum is perhaps the biggest challenge of the year, but whilst the SAC is responsible for the curriculum, the BOA’s Training Standards Committee leads on much of the detail. Particular thanks to Lisa HadfieldLaw for doing most of the work! >>

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JTO Features

THE SAC AND THE BOA HAVE CONTRIBUTED SIGNIFICANTLY TO WORKFORCE PLANNING. WE HAVE BEEN SUCCESSFUL IN MAINTAINING THE CASE FOR RECRUITMENT NUMBERS, PERHAPS MORE SO THAN OTHER SPECIALTIES. APPLICATION RATIOS FOR TRAINING POSTS HAVE REMAINED COMPETITIVE; ALTHOUGH SURGERY AND T&O ARE BECOMING LESS ATTRACTIVE WITH RATIOS FALLING BELOW 2:1.

We have taken the opportunity of this update, not just to include the GMC’s needs, but also to consider what is required and expected of the first day consultant in the generality of T&O surgery. The subspecialty associations have continued to support a broad based training with exposure across all. Thus the curriculum is likely to reflect more realistic expectations of the ‘level’ of operative skills achievable by the time of CCT. This, in turn, opens up the question of a curriculum for post CCT subspecialties and the potential for ‘credentialing.’

Quality assurance The external Q/A of training programmes is the core of the Liaison member’s role. They are not just passive assessors but a valuable support for TPDs. Rob Gregory is our Q/A lead. One of Rob’s and my aims is to improve the objectivity and feedback on the Q/A data. This will, we hope, allow us to compare across programmes, share best practice and ultimately drive up standards. It may also give prospective ST3 trainees objective data to inform their choice of programme. Liaison member’s feedback allows early reporting of issues adversely affecting training. There has been recent concern

about access to operative cases. There are various factors contributing to this, including shift work, loss of firm structure, outcomes/consent/registry concerns, commissioning, independent outsourcing and rotation boundary changes. These are all challenges we actively monitor and hopefully provide solutions to in order to maintain both the opportunities for and quality of training. Out of programme training (OOPT) can be useful if a particular subspecialty is not available within programme. Nevertheless, we are keen to make them the exception, rather than the rule. Alan Norrish and I are working with BOA to expand OOPT’s in the developing world, as in this case they can provide superb training, in trauma or infection for example.

CCT guidelines The SAC is responsible for recommending trainees for their Certificate of Completion of Training. Trainees’ ISCP portfolios are assessed against ‘minimum’ guidelines. Whilst these guidelines sit outside the curriculum, reading them might be as close as many trainees get to reading the curriculum! An unintended consequence is that that they have been seen as a tick box for training.

There has been a request from GMC to standardise the research/ academic guides between specialties, consequently these are being revised. We also feel that the numbers of indicative procedures needs an overhaul. Bill Ryan is leading a consultation and will soon report. We are expecting to produce an indicative list based on three core principles; operative procedures, anatomical areas and emergency safe. Watch this space.

Culture As I begin my tenure BOTA has reported on bullying, undermining and harassment. The SAC and JCST are both fully supportive of the #CutitOut campaign and are keen to promote improved awareness, training techniques, mentorship and will work with BOA/BOTA to do so. Women continue to be in the minority in our specialty. If we are to maintain our numbers then we must overcome this. This may mean that the culture and methods of training need to change.

Want to join us? The challenges to training over the next years are significant; I am delighted to have the opportunity to help shape the

solutions. I am indebted to the work of my predecessor, David Large, and glad to have a great team at the SAC to share the load. If you would like to join our LM team and have a track record in training then there are vacancies - we would be delighted to receive your application www.jcst.org/news/sacmembership-vacancies-traumaorthopaedic-surgery. n Mark Bowditch is a consultant orthopaedic surgeon and divisional Director of surgery at Ipswich NHS Trust. He is a current Trustee of the BOA and chairs the T&O speciality training committee for the East of England. He is a member of the East of England school of surgery, a FRCS orth examiner and chair of the T&O SAC for UK and Ireland. Mark also sits on the BOA training standards committee and education board.

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Operations I no longer do... Conventional posterior approach for total hip replacement John Timperley The moment of change occurred 18 months ago when I was learning to carry out total hip arthroplasty through a direct anterior approach (DAA). My driver for learning DAA was that whilst the conventional posterior approach gives the best exposure and, arguably, the best function and PROMS scores following total hip replacement, most centres, including my own, report a dislocation rate in excess of 1%.

Whilst this is not a common complication it can lead to further hospital admissions and adverse psychological consequences for the patient. Most centres also restrict the patientâ&#x20AC;&#x2122;s activity for the first six weeks and assess them for aids, such as chair and toilet raises. I hoped we could avoid this.

John Timperley

My experience with DAA was not a happy one. I visited multiple surgeons on several continents, carried out multiple cadaver courses and was formally mentored by three experienced DAA surgeons. Anecdotally I could not detect any early benefit, I did not observe the operation to be truly tendon-sparing, even in the most experienced hands, and there was an unacceptable

incidence of patients complaining of groin pain. I abandoned DAA after 20 cases. I re-learned the anatomy of the hip. The trochanteric attachment of the short external rotators has recently been studied in detail.

Usually Obturator Internus is inserted in a more caudal, anterior and medial position than Piriformis.1 The short external rotators have been shown to act together as a Quadriceps Coxae, which functions as a primary abductor and extensor of the hip from flexed positions2, being important when rising from seated and in propulsion. It became apparent that hip arthroplasty could be performed leaving all the tendons, except Obturator Externus, intact. In Exeter we developed a technique appropriate for all routine primary THR in which we Save Piriformis And (Obturator) Internus with Repair of (Obturator) Externus (the SPAIRE technique). An approach is developed in the interval between the Inferior Gemellus and Quadratus Femoris (Figure 1) >>

Figure 1: The interval is developed between the Inferior Gemellus and Quadratus Femoris

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such that Obturator Externus is the only tendon divided. This is ultimately repaired along with the posterior capsule. In practical terms, leaving most of the Quadriceps Coxae intact confers benefit in judging leg length and offset. A bone hook is invariably necessary to dislocate the joint after trial reduction as the intact Obturator Internus passes over the head at, or below, the centre of rotation of the hip and acts as a strap holding the joint reduced. Confirming the old adage that there is “nothing new” in orthopaedics, several surgeons in South Korea have been carrying out surgery through the same interval. In 2008 Kim compared the dislocation rates with routine posterior, posterior plus repair and external rotator preservation.3 The diagnosis was AVN in 83% of the preservation group and most patients had a low BMI. He considered that the procedure “may have limited application in patients with primary osteoarthritis, osteonecrosis of the femoral head, or rheumatoid arthritis”. The results in hemiarthroplasty in a series of patients with neurological disorder have also been published.4 In unpublished work, Dr Song reviewed his dislocation rate in a large number of patients having their hips replaced preserving the external rotators (personal communication with Mr G.A. Gie, June 2016). Although a THR can be carried out through the described interval with conventional surgical trays, the operation is greatly facilitated by using dedicated instruments.5 In collaboration with Platts and Nisbett of Sheffield, SPAIRE instruments (Figure 2) have now been designed to allow

socket exposure (Figure 3) and femoral preparation (Figure 4) without damage to the Quadriceps Coxae. Any profit from these instruments will be donated to an orthopaedic research Charity. Total hip replacement is such a successful operation that large numbers of patients are required to demonstrate any potential advantages of an improvised procedure. Over the eighteen months I have routinely used this technique there has been no recorded complication or re-admission within 30 days. Initial baseline data indicates similar radiological appearances and equivalent recovery when compared with a conventional posterior approach. Several randomised prospective studies are ongoing including the use of gait-analysis and measurement of muscle power. Whilst it will take time to prove the benefits of SPAIRE my anecdotal impression is that it confers benefits for hip stability, a lack of postoperative restriction (indeed I encourage full immediate flexion of the hip) and the return of improved range of motion and function. I would now be very unhappy to return to a conventional posterior approach to the hip. n John Timperley was President of the British Hip Society (20132014) and is Chairman of the Exeter Hip Foundation. He was elected to the Council of the BOA where he served for three years and was Hon. Treasurer of the Association between 2012 and 2013. His specialist practice is focused on hip replacements, including routine and complex cases, and revision (re-do) procedures. His team develops the Exeter Hip and innovates advanced surgical techniques used in hip replacement.

Figure 2: Instruments to Save Piriformis and Internus, Repair Externus (SPAIRE)

Figure 3: Socket exposure is facilitated by supporting the hip in a position of 800 of flexion, slight abduction and variable rotation, with the use of an offset retractor between the posterior capsule and femur

Figure 4: A slot is developed behind the attachments of Obturator Internus and Piriformis to the medial surface of the greater trochanter

References: 1. Ito Y, Matsushita I, Watanabe H, Kimura T. Anatomic mapping of short external rotators shows the limit of their preservation during total hip arthroplasty. Clin Orthop Relat Res 2012, Jun;470(6):1690-5. 2. Vaarbakken K, Steen H, Samuelsen G, Dahl HA, Leergaard TB, Nordsletten L, Stuge B. Lengths of the external hip rotators in mobilized cadavers indicate the quadriceps coxa as a primary abductor and extensor of the flexed hip. Clin Biomech (Bristol, Avon) 2014, Aug;29(7):794-802.

3. Kim YS, Kwon SY, Sun DH, Han SK, Maloney WJ. Modified posterior approach to total hip arthroplasty to enhance joint stability. Clin Orthop Relat Res 2008, Feb;466(2):294-9. 4. Han S-K, Kim Y-S, Kang S-H. Treatment of femoral neck fractures with bipolar hemiarthroplasty using a modified minimally invasive posterior approach in patients with neurological disorders. Orthopedics 2012, May;35(5):e635-40. 5. Hanly RJ, Sokolowski S, Timperley AJ. The SPAIRE technique allows sparing of the piriformis and obturator internus in a modified posterior approach to the hip. Hip Int 2017, Feb 8:0.

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National Joint Registry Data Quality Audit Martyn Porter Data quality and validation are essential components of any audit or scientific research. As such, the NJR’s programme of work to improve the quality of our data has been a key focus in recent years, driven through the NJR’s ‘Supporting Data Quality Strategy’.

Key to this strategy has been the NJR’s national programme which is aimed at assessing data completeness and quality within the registry. Known more simply as the Data Quality Audit, the programme, which has just completed its second year, has allowed the NJR to compare the records in local hospitals’ databases to the registry records, with the aim of ensuring the accuracy of the number of arthroplasty procedures submitted, compared to the number carried out. Although any NHS hospital carrying out hip or knee surgery is mandated to submit all eligible primary and revision procedures to the NJR since 2011, the Data Quality Audit has highlighted that many continue to have problems achieving this.

Martyn Porter

Completing the audit’s first year has been a huge achievement; it began in July 2015 and by July 2017 137 of 149 eligible NHS Trusts and Health Boards had fully completed the audit. The high rate of completion offers an incredibly powerful snapshot of NJR data quality within the NHS.

We’re now able to fully report the audit’s findings in year one. These findings can be found online at www.njrcentre.org.uk. The takeaway message is that the overall scale of missing records was found to be low, at only 5.9%. However, the proportion of missing revision records was found to be higher than that for primary procedures. The audit shows 5.8% of hip primaries are missing compared to 9.6% of hip revisions. Similarly 4.7% of knee primaries are missing, compared to 11% of revisions. The failure of hospitals to upload revision procedures into the NJR is concerning, as linked revision procedures form the basis of the analysis of implant failure and surgical performance – which fundamentally underpin the core purpose of the NJR. To put the importance of this into context, if systematic under-reporting of revision procedures is occurring, this is likely to bias results and reduce the statistical power of the NJR to quickly detect failing implants at higher than expected rates.

Further investigation is required to ascertain whether these are random events or a systematic under-reporting of revision procedures. Analysis of the audit’s results in year two will help this and that work is currently underway. We have already seen a number of NHS hospitals demonstrate a marked improvement in data quality following the previous year’s audit process. However, we know that some hospitals continue to struggle with the process and have resource problems. The NJR’s ‘Supporting Data Quality Strategy’ will continue to help hospitals overcome these barriers, so that all collect high quality, complete data. We look forward to updating BOA members at the BOA’s Annual Congress in Liverpool. n Martyn Porter is the National Joint Registry’s medical director and vice chairman, appointed by the Department of Health from 1 February 2014. Mr Porter is a consultant orthopaedic surgeon based at Wrightington Hospital, Lancashire, a past-President of the British Orthopaedic Association (BOA) and immediate past-President of the International Society of Arthroplasty Registers (ISAR).

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JTO Features

How I Do… Percutaneous Fixation of Depressed Intra-Articular Calcaneus Fractures Jamie A Nicholson Co-authors: LZ Yapp, Robert AE Clayton The management of Displaced Intra-Articular Calcaneal Fractures (DIACF) is controversial following the UK Heel trial1. This is partly because of the morbidity associated with the extensile-lateral approach. However, there is now increasing evidence that percutaneous techniques result in satisfactory patient outcomes with significantly reduced rates of wound complication and deep infection2,3,4. Numerous methods have been described from simple Steinmann pin reduction to complex procedures with arthroscopic assistance5,6. We have been using a percutaneous fixation method for over five years. Pre-operative CT scans are obtained in all cases. Surgery is usually performed within a week of injury except in rare cases of severe skin tenting.

Surgical technique

Jamie A Nicholson

The patient is placed in the lateral position with the foot raised. The image-intensifier is positioned at the end of the table, such that it can easily be rotated from a lateral to a Harris-axial view without moving the foot.

A guide wire is driven into the largest displaced articular fragment. This wire is used as a joystick to elevate the depressed fragment, restore height and reduce the posterior facet. Occasionally restoration of Bohler’s angle is assisted by inserting a periosteal elevator through a small incision below the depressed articular fragment in the sinus tarsi (Figure 1). The hindfoot varus is then reduced with two 6.5mm cannulated-screw guide wires being driven along the tuberosity towards the anterior process to restore heel valgus.

In tongue-type fractures guide wires for the 4.5mm partially threaded cannulated-screws are placed into the tuberosity. If there is no comminution of the body, the body acts as a fulcrum further around which to reduce the posterior facet (Figure 2). In joint-depression fractures the same wires can be passed latero-medially across the primary fracture-line into the constant, sustentaculum tali fragment to fix the posterior facet fracture (Figure 3). Final screw insertion is then undertaken. Two 6.5mm screws are inserted over the provisional wires into the anterior process of the calcaneus. It is essential that these are fully-threaded to >>

Figure 1: Reduction of the posterior facet ‘tongue type’ component

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JTO Features

Figure 2: Tongue type fracture. a) Pre-operative b) Post-operative

avoid shortening the calcaneus. These two screws form a raft to support the posterior facet fragments, preventing late depression and loss of reduction. n Jamie Nicholson is a Specialist Trainee (ST5) in the South East Scotland rotation with an interest in trauma. He is currently a Clinical Teaching Fellow at the University of Edinburgh in addition to undertaking a period of research out of programme.

References b

1. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, et al. Operative versus non-operative treatment for closed, displaced, intraarticular fractures of the calcaneus: randomised controlled trial. BMJ 2014 Jul 24;349:g4483. 2. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int 2013 Jun;34(6):773-780.

Figure 3: Joint depression type fracture. a) Pre-operative b) Six months post-operative

3. Wallin KJ, Cozzetto D, Russell L, Hallare DA, Lee DK. Evidence-based rationale for percutaneous fixation technique of displaced intraarticular calcaneal fractures: a systematic review of clinical outcomes. The Journal of Foot and Ankle Surgery 2014;53(6):740-743. 4. Hammond AW, Crist BD. Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: A case series. Injury 2013;44(11):1483-1485. 5. Abdelgaid SM. Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. Foot and Ankle Surgery 2012;18(3):164-179. 6. Sivakumar BS, Wong P, Dick CG, Steer RA, Tetsworth K. Arthroscopic reduction and percutaneous fixation of selected calcaneus fractures: surgical technique and early results. J Orthop Trauma 2014 Oct;28(10):569-576.

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s Q was a young shop worker living in the south of England. She had been experiencing lower back pain for several months and it had not responded to conservative treatment. The results of an x-ray had been inconclusive and, rather than wait to have further investigations as an NHS patient, Ms Q asked her GP to refer her to an orthopaedic surgeon as a private patient. She saw Mr K, who arranged for an MRI scan. This showed “a moderate sized left para-central disc prolapse indenting the theca and displacing the left L5/S1 root”. This short radiologist’s report is the only existing document relating to the immediate pre-operative period. Mr K’s private practice notes were destroyed soon after he retired. Mr K apparently recommended surgery and undertook a consent process. Ms Q was admitted for a discectomy at L5/S. Although the operation was unremarkable, Ms Q subsequently experienced pain, pins and needles, numbness and muscle spasms in her mid-back and legs.

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Learning points • The absence of notes made it almost impossible to defend this claim. • It is essential to record all patient encounters and ensure they are retained for a reasonable length of time after the treatment has finished. While there is no set minimum for care records in private practice, we recommend following the NHS Records Management Code of Practice for Health and Social Care 2016, which states records in this situation should have been kept for eight years after the last consultation. • In the absence of records, a court is likely to prefer the evidence of the patient who has only the facts of a few important consultations to remember, whereas the doctor will have had thousands of patient consultations before and after the alleged incident.

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Investigations failed to identify a clear cause for these persisting symptoms and efforts to treat them were largely unsuccessful; spinal epidurals and a nerve root block failed to alleviate the pain. Ms Q’s claim against Mr K – brought a year after the procedure − alleged negligence in that the surgery was not indicated and Mr K had not warned Ms Q of the risks and the chances of success.

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JTO Features

High Impact Presentations for Surgeons Lisa Hadfield-Law Effective presentation skills are invaluable and, like surgery, the key to success is planning. Before planning, ask yourself: “What is this presentation for”? Is it to inform, educate, persuade, or motivate? Having defined the purpose in 10 words, you can plan how to move your audience from where they are, to where they should be: from A to B. What are the obstacles? Presenters everywhere make the same mistakes: no clear point; no audience benefit; poor flow; too much detail and too long. The commonest mistake is the ‘data dump’: the belief that, for the audience to understand anything, they must be told everything. It’s like being asked the time and responding with instructions for building a clock. Mountains of information are then crammed into a presentation and “delivered”, without straightening the A to B route. Point B should address issues the audience cares about, not the ones you THINK they should care about.

Planning is the key

Lisa Hadfield-Law

Who will be there? Define what they should DO when they leave your presentation, whether you want them to change their practice or give you a job. Once

your outcomes are articulated, you can dump data onto a page, and delete anything, which doesn’t contribute to the A to B route. Present your most convincing arguments first, so the audience can see how all the elements: relevant evidence, data and methods fit together. Newscasters begin with the most relevant information.

Visual aids Visual aids should be visible and aid. Most overload slides with images and text, hoping to have all bases covered. Always start preparation with a blank slide, so you are forced to consider everything you include. Use sharp contrast: light text on a dark background or vice versa. Leave blank space: you don’t need to fill every area. Remember: a picture paints a thousand words. Numbers should be presented visually, rather

than in tables. Graphs are an opportunity to provide a quick visual of your content. Your presentation is NOT the place to go into minute methodological detail, but an opportunity share the most important elements. So, no more than five eye sweeps per slide: the number of times eyes must go across the screen. Text should be in sans serif fonts eg Arial or Verdana which are quicker to read than Times New Roman. It’s also quicker to read lower case font THAN UPPER CASE. Size should be a minimum of 24 to 28 points. The universal “thank you” slide has no place as, what the audience hears last, they will remember. Make sure you end with your three key messages. So, powerful presentations take planning to get the audience directly from A to B, with high impact visual aids. They can’t read your slides, listen to you, take notes and analyse content at the same time. Start with a preview of your conclusions to engage and end with a strong call to action. For other tips from Lisa on presenting effectively can be found online at www.grasshopperhosting.co.uk/hl/06_Resources/ Resources/PowerfulPresentations. mp4. n Lisa Hadfield-Law, RGN, MSc, FAcadMEd and Education Advisor to the BOA.

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Volume 05 / Issue 03 / September 2017

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JTO Features

Supporting Student-Led Orthopaedic Conferences Improves Understanding and Perceptions of the Field Conor S Jones, Praveena Deekonda Co-authors: Alexis King, Tobi Onafawoken, Hollie Campbell, Adrian Hughes, Oliver Stokes Exposure to orthopaedic surgery during undergraduate training has declined in recent years.1 Therefore, in order to ensure the continued recruitment of high caliber trainees, orthopaedic surgeons must reach out and showcase their specialty. Undergraduate surgical conferences and career days provide an opportunity to address many students in a relatively limited time period. What was done? Now in its second year, the South West Orthopaedic Conference was organised by a group of undergraduates, supported by Mr Oliver Stokes (consultant spinal surgeon) and Mr Adrian Hughes (consultant foot and ankle surgeon) from Exeter. The day consisted of morning lectures followed by poster presentations, practical workshops in total hip arthroplasty, fracture fixation, suturing and plaster casting (Figure 1).

Conor Jones

Praveena Deekonda

Forty-seven medical students and five junior doctors attended the event. Twenty-three travelled from outside of the region. Delegates were asked to complete identical questionnaires immediately before and after the conference.

Improving insight The current training pathway requires medical graduates to decide upon their career trajectories at an earlier stage than in previous generations.2 Despite this, only 43% of our delegates reported a good understanding of the orthopaedic training pathway and only 25% understood what is required to obtain a training post. Senior medical students did not appear to be any more enlightened than pre-clinical students with regard to the training pathway (P= 0.13). More worryingly these figures, in all probability, overestimate the enlightenment of the student population as a whole, given the selected nature of the students attending the conference. Lectures dedicated to these themes should therefore form an essential component of these events. Following the conference, we saw significant improvements in all areas of understanding (Figure 2, P<0.001).

Motivating factors Overall motivation to pursue a career in orthopaedic surgery was increased following the conference (Figure 3). Varied caseload, the range of subspecialties available and an

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Figure 1: The opportunity to present research projects and participate in practical workshops were a key element of the conference

Figure 2: Pre and post conference understanding of orthopaedic careers and training

interest in musculoskeletal disease were the most commonly reported motivating factors (Figure 4).

the UK, to support student-led initiatives with the aim of promoting recruitment to the specialty. n

A lecture dedicated to the development of the Exeter Hip was included in the course to illustrate the research and innovation intrinsic to orthopaedics. The lecture was well received and may account for the increased number of responses listing ‘academic opportunities’ as a motivating factor in the postconference questionnaire (p=0.005). Similar lectures may therefore represent a useful tool in overcoming traditional misconceptions and stereotypes surrounding orthopaedic surgery as a career.

Conor Jones is currently interrupting his medical studies to undertake an intercalated Master’s by Research degree at the University of Exeter. Conor has been awarded multiple national prizes, including the 2017 BOTA Junior Essay Writing Competition, and intends to pursue a career in academic surgery.

Deterrents to entering orthopaedics

Figure 3: Pre and post conference motivation to pursue a career in orthopaedic surgery

Work-life balance and a lack of exposure were the most commonly reported deterrents to entering the field. In contrast to previously published work, no significant differences were observed between genders.3-5

Final word

Figure 4: Perceived motivating factors in pursuing a career in orthopaedics

Dedicated orthopaedic conferences appear to improve understanding, perception and motivation for students to pursue a career in orthopaedic surgery. Although this event was organised by students, the support of consultants was pivotal to its success. Not only are consultants able to open networks to colleagues and representatives within industry; their support also serves to provide a sense of credibility when approaching potential sponsors and faculty. We therefore encourage other orthopaedic surgeons, throughout

Praveena Deekonda is a final year medical student at the University of Exeter, and aspiring academic surgeon. She currently serves as a research student in the Royal Devon and Exeter Spinal Surgery Department and is interested in surgical simulation and global surgery.

References 1. Turner P. From the Editor. JTO. 2017;5(1): 3. 2. Goldacre, M., Lambert, T., and Surman, G. UK-trained doctors’ early career choices and career progression in individual surgical specialties. Bull R Coll Surg Engl. 2013; 95: 1–6. 3. Yu TC, Jain A, Chakraborty M, et al. Factors influencing intentions of female medical students to pursue a surgical career. J Am Coll Surg. 2012;215:878–89. 4. Rohde RS, Wolf JM, Adams JE. Where Are the Women in Orthopaedic Surgery? Clin Orthop Relat Res. 2016;474(9):1950-6. 5. Gargiulo DA, Hyman NH, Hebert JC. Women in surgery: do we really understand the deterrents? Arch Surg. 2006;141:405–7.

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JTO Features - Trainee Section

The Junior Doctor’s Contract; What’s Happening Now? Patrick Williams, Jeeves Wijesuriya In November 2015 the British Medical Association (BMA), threatened with the imposition of a new Junior Doctor contract, sought and received a 97% mandate for industrial action from their junior members1. This led to unprecedented industrial action in early 2016, culminating in a series of strikes and the removal of emergency care. Junior doctors felt that the government was trying to stretch already struggling services, removing the recognition of anti-social hours. This would heavily impact on those working in acute specialties.

This was done under the guise of reducing weekend mortality in the government’s push for a seven day NHS2. Following Negotiations, led by BMA Junior Doctors Committee (JDC) chair Dr Johann Malawana, the contract offer was improved, with protections around training and new safety limits on hours established. In a second vote 58%3 of the BMA’s junior membership again voted to reject the new terms and conditions. So where are we now?

Patrick Williams

Jeeves Wijesuriya

As the British Orthopaedic Trainees Association’s BMA representative I have had

a chance to sit in on JDC meetings and get to know some of the key players. Amongst those is current JDC Chair Dr Jeeves Wijesuriya with whom I have discussed a number of the key issues facing Orthopaedic trainees.

State of Play The BMA remains opposed to the new contract. With the previous mandate in the balance, 42% of junior members voted to accept the improved terms and conditions, the BMA has continued in talks to improve the remaining areas of concern. These talks have led to an agreement that there will be an independent gender pay gap review, an increase in unbanded Foundation Year 2 trainees pay protection and a further investment in return to training for trainees who return from maternity leave. There has also been work on a code of practice for employers on rotas and help in refining the new role of the Guardian in ensuring the provision of adequate training. Understandably, in the wake of the government’s imposition of the contract, there remains a broad sense of dissatisfaction, in particular

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Page 53

changes to the definitions of plain and premium time as well as the effects of changes on part-time trainees. This is most notable on social media where the tone has changed drastically, with some Junior Doctors outspoken in their criticism of the contract, and many still hoping for further improvement in several key areas. The government began imposing the new contract in October 2016. Since then it has been rolled out as individuals have rotated. The majority of Orthopaedic trainees will move to the new contract this autumn. Some have noticed

that their pay is probably slightly higher than it would have been otherwise. Despite the new contract being said to be cost neutral; pay protection and exception reporting costs come from outside this envelope. Despite all this, concerns remain around the way pay is structured with less weight being given to anti-social hours. This may have far reaching consequences.

Impact on Orthopaedics

our ST3 will be out earning our ST5 trainees. This is as a result of the front loaded pay structure, created to compensate for the loss of annual pay protection. Pay is now front loaded with no annual increment with experience gained. This is balanced by raising early pay points, most notably that of an ST3 to an ST7 rate. This was to reduce the impact on pay for trainees taking time out at the earlier stages of their career.

The most immediate affect we will see in orthopaedics is that

Those already in specialty training will retain the previous

contract’s annual increments. Over the course of training this will be equitable. However, this pay protection ends in 2022 or after four years of full time service. For anyone going out of programme to do research this means that they will not attract the increased early years training. This needs to be borne in mind by anyone thinking of going out of programme. For those leaving training for NIHR or ACF posts an Academic premium has been established, meaning pay is added to incentivise those in these posts. >>

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Volume 05 / Issue 03 / September 2017

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boa.ac.uk

JTO Features - Trainee Section

THE MOST IMMEDIATE AFFECT WE WILL SEE IN ORTHOPAEDICS IS THAT OUR ST3 WILL BE OUT EARNING OUR ST5 TRAINEES. THIS IS AS A RESULT OF THE FRONT LOADED PAY STRUCTURE, CREATED TO COMPENSATE FOR THE LOSS OF ANNUAL PAY PROTECTION. PAY IS NOW FRONT LOADED WITH NO ANNUAL INCREMENT WITH EXPERIENCE GAINED.

We will also see changes in how non-residential on calls (NROC) work is paid. These now attract an even lower out of hours ‘availability’ uplift. Trusts will have to estimate how much of the NROC shift a trainee will spend in the hospital. This will then affect the hours they are able to work the following day. If a trust is repeatedly underestimating NROC time, as shown by exception reporting, then they are liable to be fined and the shift pattern reviewed. Currently the BMA and the various College trainee groups are working on rostering and NROC guidance to help establish best practice for trusts. The biggest change is probably going to be exception reporting, which requires junior doctors to report when their work pattern varies from what is agreed. This replaces the previous banding appeal system. There will be a greater emphasis on work role definitions, as well as expected training opportunities. If training opportunities are consumed by service provision, or can only be met by working beyond agreed hours, then this will need to be reported. There are positive and negative aspects to this. Trusts may not be keen for trainees to exception report and so they may insist that people do not stay back to help with an

operating list, with negative effects on training. Conversely, if trainees are not getting adequate training opportunities, collection of the data will mean that trusts will have to review rotas to increase training within the agreed hours. Thus exception reporting will provide departments with the evidence required to justify better staffing. Live recording of this information will hopefully allow evidencebased scrutiny from organisations such as the GMC or Health Education England (HEE).

Patrick Williams is currently working as an ST4 in Trauma and Orthopaedic surgery in the Northern Deanery. He also sits on the BOTA Committee as their BMA representative.

Where next?

References

The fight for a better contract is not over, but it has evolved. We have moved from picket lines to trust board meetings, from public statements to data collection. These will be used to prepare for the upcoming review of the contract, allowing areas where the contract falls short and reinvestment is needed to be identified.

1. BMA Press Release; Juniors vote in favour of industrial action; 15th September 2015.

This incremental approach may not make for eye-catching headlines but it is slowly working. None of us wanted to start from where we were late last year - but the BMA has to deal with what is in front of it. “I can’t promise immediate resolution, that would be a fantasy, but I can offer you the reality of a hard road back, mile by mile, to better conditions”4. n

Jeeves Wijesuriya is an Chair of the BMA Junior Doctors Committee. He has an interest in Medical Education and is currently completing a Masters in this Field. Currently completing Academic GP training, Jeeves is passionate about improving quality and access to training.

2. Jeremy Hunt; Radio 4; Today Programme; 16th July 2015. 3. BMA Press Release; Junior doctors reject proposed contract; 5th July 2016. 4. J Wijusriya; The fight is not over. The fight has evolved; 1st June 2017.

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Volume 05 / Issue 03 / September 2017

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JTO Medico-Legal Features

Conferences in medico-legal cases - don’t get ambushed Michael A Foy I want to tell you a story. In my 28 years as a consultant I have provided a lot of expert reports in both personal injury and clinical negligence cases. Therefore, invariably, I have attended a lot of conferences with solicitors, barristers and other experts. This area is covered in the BOA “Code of Practice for Orthopaedic Surgeons Preparing Reports in Personal Injury and Other Cases” (2014).

This is downloadable in a pdf from the Association’s website (link in reference). As discussed therein, the purpose of such meetings is usually to clarify issues in relation to the veracity of the claim (or defence) and to ensure that the legal team properly understand the nature of the medical issues involved.

Michael A Foy

Conferences may take place over the telephone, via video link or in person. It goes without saying that the expert should spend some time thoroughly familiarising himself with the facts and opinions provided in the case ahead of any conference as the barrister

no doubt will have done so. The legal team usually want the expert to attend in person, but they understand that busy clinicians can find it difficult to take a half day or day out of their schedule and will usually settle for attendance over the telephone. Sometimes they will insist on the expert attending in person. This is when the antennae should come out. On most occasions this is either because the issues in the case are particularly complex, sometimes in clinical negligence cases the legal team want the expert in the same room as the claimant or accused clinician. However, most often in my

experience it is because the barrister wants to “test” the expert to see how well he is likely to stand up to vigorous questioning from his opposite number in the witness box if the case proceeds to Court. This leads in quite nicely to the story that I want to tell you; the other reason for attendance in person is to ambush the expert! I was recently asked to attend a conference in person in a personal injury case where I had provided an expert report for the defence (via the solicitors acting for the insurers). The case involved a claimant who had quite severe (potentially life-threatening) injuries including spinal fractures. When I read through the file and documents a few days before the conference I was surprised that I was being asked to attend in person because the issues seemed relatively straightforward. I asked my secretary to check with the instructing solicitor that they definitely wanted me there in person as it was a four hour round trip. They confirmed that they did. As it was in the diary and therefore clashed with no other commitments I thought no more of it and went ahead. As one does in the 21st century I picked up my mobile telephone

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to check my emails at 10pm before wandering off to bed. I was intrigued to see an email (sent at 9.30pm), from the solicitor who had instructed me whose name I recognised as I was familiar with the file having recently reviewed it. My first thought was that the conference was cancelled or they had decided that there was no need for me to attend in person. But no, the email had an additional expert report attached to it that I had not previously seen. The report had already been disclosed to the

boa.ac.uk

other side and was dated some months earlier. The report was from a speciality allied to my own (pain management). The solicitor apologised profusely for the late disclosure indicating that the barrister wanted me to see it ahead of the conference which was due to take place the following morning. I didn’t think too much about it but resolved to read it on the train the following morning en route to the conference. I duly did this and noted that there were no major differences between myself and the allied expert, except that his prognosis (already you will recall

disclosed to the other side) was, shall we say, a little more optimistic than the prognosis given in my own report. Still a rat was not smelt by yours truly. At the conference were myself, barrister, solicitor, solicitors’ assistant and the pain expert. The pain expert was on the speaker ‘phone. A little strange I thought. I had not been told (and had not asked) but was informed that my report had not yet been disclosed and the legal team would like me to “tidy it up a bit” prior to disclosure to the claimants solicitors. It soon

became abundantly clear that what they actually wanted was for me to remove significant paragraphs of flowing prose and defer to the pain expert in terms of prognosis, given that the claimant was no longer under the care of an orthopaedic/spinal surgeon. The pain expert’s report was obviously significantly more favourable to the insurer in terms of the compensation that would be paid to the claimant. The barrister politely explained that the Courts were easily confused and liked evidence >>

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JTO Medico-Legal Features

IT SOON BECAME ABUNDANTLY CLEAR THAT WHAT THEY ACTUALLY WANTED WAS FOR ME TO REMOVE SIGNIFICANT PARAGRAPHS OF FLOWING PROSE AND DEFER TO THE PAIN EXPERT IN TERMS OF PROGNOSIS, GIVEN THAT THE CLAIMANT WAS NO LONGER UNDER THE CARE OF AN ORTHOPAEDIC/SPINAL SURGEON.

to be compartmentalised as much as possible. Judges apparently find it difficult if there is overlap or conflicting opinion from experts on the same side. I explained that whilst I sympathised with this approach it did not accord with reality. I explained that in clinical practice we have regular multi-disciplinary team (MDT) meetings because of the failure of clinical problems to compartmentalise themselves. I also explained that I did not believe that it was appropriate to remove tracts of flowing prose and defer to my allied expert colleague when my opinion on the prognosis differed from his. A rather heated exchange took place if truth be known. The conclusion of this episode was that I presented them with two options, sack me and instruct someone else in my field or allow me sufficient time to consider the expert pain report in more detail and, if I felt it appropriate to do so, modify my report in light of that consideration. The latter course was eventually agreed. What can we learn from all this? Am I suffering from paranoia? Clearly there are two possible explanations for the disclosure to me of a report pivotal to a face-to-face conference that was due to take place approximately 12 hours later. The first of these is gross incompetence on behalf of the

solicitor +/- barrister. Obviously the correct course of action would have been to send me the allied expert report in good time ahead of the conference so that I could properly consider its contents and either comment upon it or amend my report as appropriate. Over the years I have seen a lot of incompetence in the legal management of medico-legal cases and no doubt the legal profession can point to a lot of similar incompetence from their experts. This would be the charitable interpretation of events, simple incompetence. The second explanation is the one alluded to above (the paranoia scenario) that is they wanted to throw me a last minute fastball in order for me to agree to changes/ concessions before I had a proper chance to consider the evidence. I think I favour the latter scenario. Strangely enough, since drafting the above, I have been involved in another conference over the telephone on a complicated spinal infection/ cord compression case where in my liability and causation report I had recommended that an expert spinal/neuro radiology report should be commissioned to help clarify some of the issues. I was asked for my views on the report and how it had impacted on my opinion when I had not been provided with it! Paranoia was not a

consideration in this case as it was clearly incompetence given the discomfiture between the solicitor and barrister during the conference. Therefore :1. Beware receipt of last minute information before meetings, conferences etc. Raise the antennae, be paranoid. In view of the second case described above, don’t assume that the solicitors will necessarily send you all the relevant information, you may occasionally have to request it. 2. Remember your instructing solicitors are not always on your side, nor necessarily should they be. They represent their client (insurer or claimant) and will probably do whatever they reasonably can to change your view so that it is as supportive as possible to their clients’ case. 3. Remember that the Civil Justice Councils “Guidance for the Instruction of Experts” (2014) does state that experts should not be asked to amend, expand or alter any parts of reports in a manner which distorts their true opinion, but may be invited to do so to ensure accuracy, clarity, internal consistency, completeness and relevance to the issues. 4. Follow the BOA guidelines, but still expect the unexpected. n

Michael Foy is a Consultant Orthopaedic and Spinal Surgeon. He is Chairman of the BOA’s Medico-legal Committee, coauthor of Medico-legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.

References 1. www.boa.ac.uk/wp-content/ uploads/2014/08/Guidelines-forexpert-reporting-Final1.pdf. 2. www.judiciary.gov.uk/wpcontent/uploads/2014/08/ experts-guidance-cjc-aug-2014amended-dec-8.pdf.

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JTO Subspecialty Section

Modularity in Orthopaedics Professor Michael M Morlock, Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany The original â&#x20AC;&#x153;Morse taperâ&#x20AC;? was invented by Stephen Morse in the 1860s for machine tool operators, to install or remove tool bits quickly and easily whilst maintaining precision. In Orthopaedics modularity was first introduced for Total Hip Replacement (THA), as a result of the need, to combine different materials, for example cobalt-chromium or ceramic heads on titanium-alloy stems. Modularity also allowed the prosthesis to be adapted to the patientâ&#x20AC;&#x2122;s anatomy. These two benefits of modularity have contributed to the clinical success of joint replacement. In the early 1990s, 90% of femoral stems ion use were modular1. It was recognised that the head of an implanted THA is exposed to torque as a result of joint friction, although the difference between the fixation strength and the friction torque was not as great as expected. Nevertheless, assembly and loading is crucial to optimise taper connection strength2. Problems with modularity were recognised2-5, but despite these problems, designs with additional modular connections such as bi-modular primary stems and modular revision stems were introduced (Figure 1).

Professor Michael M Morlock

Several other design modifications occurred at around the same time. These included reduction of the taper length and diameter to increase the range of

motion, whilst increasing the diameter of the prosthetic head to prevent dislocation6. These larger heads, articulating with traditional polyethylene (PE)

increased PE wear. Therefore metal-on-metal (MoM) joints became more popular, as studies indicated that MoM bearings greater than 32mm in diameter produced less wear7. Unfortunately the opposite occurred in practice with MoM bearings above 32mm diameter causing 41% of metal related pathologies8. This could be due to the breakdown of the required fluid film, leading to unfavorable lubrication for large MoM joints9,10. However, there was also an increase in the popularity of minimally invasive surgery (MIS), and the small incisions might have led to increased taper contamination as well as difficulties assembling the taper accurately. Both of these factors can increase the risk

Figure 1: Contemporary primary and revision hip replacement systems with neck modularity

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for fretting corrosion6. These design and surgical issues, combined with increasing patient weight and activity, may explain the increased fretting and crevice corrosion at the taper interfaces of modular components5. In any case many bi-modular stems and MoM bearings with large diameters have been taken off the market.

Loading of Tapers: Tapers are designed to be loaded along the taper axis and perform poorly under a

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bending load. In the patient the magnitude of the bending load is influenced by many factors including the stem offset, head length, head diameter and especially the lever arm between the hip joint and the taper interface. Higher bending loads are associated with an increased risk of micromotion at the taper interface, which is directly related to the risk of fretting corrosion. Consequently it is unsurprising that there is a higher rate of metal related pathologies with modular components and an increased fracture rate of modular revision stems.

Discussion: How do we reduce the risk of clinical failure in the future? There have been 40 papers reporting retrieval analysis in the last decade. However, the analysis typically only reports the implant with no information on the other two important factors â&#x20AC;&#x201C; the surgical procedure and the patient. If the implant is the â&#x20AC;&#x2DC;root causeâ&#x20AC;&#x2122; for the failure this approach will work. However, most published studies fail to identify the root cause of failure, and failure is in fact multi-factorial.

Retrieval studies rely on the detailed description of the observed damage and changes to the implant components (Figure 2). The same damage or change then has to be reproduced in the laboratory, under defined conditions, in order to establish a causeeffect relationship. Finally completing picture using registry is essential, as the registry document the absolute frequency of the problem and averages out surgeon and patient influences. Taper corrosion is, at the present time, only indirectly >>

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JTO Subspecialty Section

HOW DO WE REDUCE THE RISK OF CLINICAL FAILURE IN THE FUTURE? THERE HAVE BEEN 40 PAPERS REPORTING RETRIEVAL ANALYSIS IN THE LAST DECADE. HOWEVER, THE ANALYSIS TYPICALLY ONLY REPORTS THE IMPLANT WITH NO INFORMATION ON THE OTHER TWO IMPORTANT FACTORS – THE SURGICAL PROCEDURE AND THE PATIENT.

documented by the registries and there is no direct registry data on different taper designs. It should be remembered that the aetiology and significance of each of the influencing factors is not yet fully understood. This is especially true in revision cases, which have already had taper problems3. Nevertheless, clinical case series, registries, retrieval and laboratory studies allow us to develop some pragmatic mechanical guidelines, to reduce the incidence of taper problems. These are: 1. Tapers are designed for torsional, not bending loading. High offset stems, long heads,

large heads, high friction in the joint, high loading in the patient, and especially modular necks and stems should be used with care. 2. Reducing the bending load at the taper interface is the most effective and immediate method to reduce the frequency of taper problems. 3. Larger taper diameter and length can increase the contact area and improve taper strength with reduced taper corrosion11. 4. Taper surface morphology, the mismatch in taper angles between female and male components, in combination with the assembly

force, are important, even if they are poorly understood factors. 5. There has never been a standard specified for taper dimension. As a consequence, tapers vary between, and even within, manufacturers. 6. Proper assembly without contamination is important. In summary, modular interfaces require appropriate assembly and loading. Each additional modular interfaces can potentially cause problems. Thus the risks of modularity have to be weighed against the clinical benefits. n

Professor Morlock is Director of the Institute of Biomechanics at the Hamburg University of Technology in Hamburg, Germany. He is a member of the “Working group on metalon-metal implants” of SCENIHR of the European Commission and of the Executive Committee of the German Arthroplasty Register EPRD. His major research interests are in preclinical testing, failure analysis, biomaterials in orthopaedics, and the interaction between implants and the human body.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

Figure 2: Metal-on-metal hip replacement, which was revised due to a fracture of the Ti-alloy stem taper inside the Ti-alloy ball head insert12. The original taper interface is indicated in the exploded diagram. The inserts show different magnifications of the corrosion cavity, which is located symmetrically to the taper interface. A 20µm thick Titanium oxide layer at the location of the original taper interface was found at the end of the cavity. The cause for the start of the corrosion process is unknown.

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JTO Subspecialty Section

Orthopaedic Robotic Surgery Professor Brian L Davies, Emeritus Professor of Robotics, Imperial College London and Istituto Italiano di Technologia Robodoc®

The earliest orthopaedic robot was Robodoc®, which was developed by IBM in 1986 for total hip arthroplasty. This gave rise to a commercial robot, which was the first orthopaedic surgical system used on humans in 1992. This was an autonomous device in which the patient was locked down and rigidly clamped. The surgeon placed the robot at the start position, pressed the on button and a predefined program carried out the task with no further activity by the surgeon, other than holding an emergency-off button.

The system was used in Germany until 2005 when a series of court actions blaming the robot for adverse outcomes were lodged. These proved to be largely unfounded, nevertheless it was sold to Curexo who continue to market the Robodoc system under the name Think Surgical Inc1. The Robodoc system has failed to gain market share, maybe as it is autonomous and the surgeon is not in control? Acrobot

Professor Brian L Davies

My own experiences commenced in 1991 with a prostate resection robot, Probot, which was the first surgical robot to be used clinically. It became apparent that autonomous robots were not appreciated by surgeons. Therefore, in 1991, I started to develop a hands-on robot for

unicondylar knee arthroplasty (UKA). The surgeon held a highspeed rotary burr on the end of the robot which he or she moved freely within an allowed region. A preoperative 3-D CT scan was used to plan ‘no-go’ regions. The robot actively limits the surgeon, providing accuracy at the limits of the cut, a concept known as ‘Active Constraint Surgery’. In 1999 Professor Justin Cobb and I started a spin-off company Acrobot. We successfully undertook minimally invasive surgery in a number of British patients2. Acrobot was sold to Stanmore Implants and then to Mako limited in 2013. Mako The Mako surgical Corporation started developing the Rio orthopaedic robot for UKA in

2004. It was based on the commercial Barrett Technology 7 DoF WAM arm. The arm was further developed and the first clinical trials conducted in 20063,4. Total hip arthroplasty was added in 2010. Mako was sold to Stryker Ltd two months after the acquisition of Acrobot for $1.65 billion. Mazor Mazor was founded in 2001. In 2004 its first product Spine Assist was the first FDA approved spinal surgery robotic system. In 2008 the Renaissance Guidance System replaced Spine Assist, allowing minimally invasive surgery with reduced fluoroscopy times and excellent results for scoliosis and complex spinal deformity. It consists of a 12cm high parallel robot, which sits on a T-bar and drills pedicle screws with 1.5mm accuracy5. Navio The Navio system was developed in Pittsburgh by Professor Jaramaz. It was used in Belgium for UKA in 2012. There is a handheld high-speed burr, which is controlled by a camera-based navigation system. The system is unusual in that it does not use a preoperative CT scan, but generates a plan based on touching the knee intraoperatively. Cutting no-go areas is prevented by a shield, which, covers the cutting burr when the tracking system dictates6. FDA approval was obtained in the USA 2012.

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Current robotic surgery Following the acquisition of the Mako system by Stryker, a number of large orthopaedic companies have acquired robotic surgery companies. This may be for prestige, to gain entry to this aspect of the prosthetic market or it may be because of a specific interest in the benefits of robotic surgery. These benefits include improved accuracy and repeatability, reduced strain on the surgeon, a structured workflow, simulation and the ability to undertake procedures that would otherwise not be possible. However, most orthopaedic robot companies

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have yet to make a profit and the major driver in the market is the selling of more prostheses. In 2016, Smith & Nephew acquired the Navio robot and Zimmer Biomet purchased Medtech, whose robot is a variant of a small industrial robot. Medtech have CE Mark and FDA clearance for its Rosa Spine system and is traditionally more involved in neurosurgery. Mazor Robotics, also in 2016, signed an agreement with Medtronic, who have recently completed a $20 million investment to commercialise the Mazor X platform, an innovative guidance system for spinal surgery7.

The same X platform also supports an abdominal robot. Thus, Medtronic, are moving from a relatively simple system to a large, generic platform which can undertake a range of surgeries. Presumably, the basis is that a costly, but multi-purpose robot, is a better business proposition than a series of simpler specialised devices. This is presumably as complex software, with safety systems, planning and simulation sits more effectively alongside the surgery specific software. It should be noted that Google are involved with Johnson & Johnson in robot surgery research, which is an

indicator that the Medtronic approach may appeal to other large organisations. As these complex and expensive systems emerge, we are also seeing a move to small, low-cost, simple robotic medical devices. These are â&#x20AC;&#x2DC;smart toolsâ&#x20AC;&#x2122; which have specific advantages for specific tasks. For example Point Robotics is producing a smart drill that has a tiny parallel robot at the tip. The drill adapts in real time to accommodate patient movement and surgical hand tremor, thus drilling more accurately8. >>

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JTO Subspecialty Section

Mazor

Why have clinical applications been so few? Given the rigid nature of bone, it would seem that orthopaedic surgery would be an obvious area for robotic applications. However, despite excellent research, clinical adoption remains low. One of the reasons is cost, even the simple Navio system retails at $400,000. Most of the costs are not in the device itself but in marketing, training, research and above all patent protection and litigation. Large companies have patented many variants, and defence of the patents is too expensive for small companies. A further problem is showing clear clinical benefit from the robot. This is not simply a comparison with conventional open ‘jigs and fixtures’ surgery, but also with navigation systems, which do not need motorised control and are cheaper. Another competitor is the use of ‘patientspecific instruments’ (PSI) in which the fixtures are generated from CT scans. Many prosthesis suppliers favour PSI as it does not rely on costly navigation or robotic systems. However, whilst PSI seems to work well in experienced surgical hands, results with trainees have been less convincing.

Navio

It is important to compare robotic to conventional surgery. Like any other new system, robots have a learning curve, typically 25 to 30 cases. Thus the first 30 cases should be excluded, and if this is taken into account it is clear that Robots produce a more accurate and reproducible result than conventional navigation or PSI. This will in turn need to be correlated with better patient outcomes, which whilst the research is underway will take time.

The future Orthopaedic robotics is at a new dawn and surgeons who hope all this ‘computer nonsense’ will disappear are in a minority. Regulatory needs are better understood and, whilst more onerous than in earlier days, are becoming more realistic. Thus although high cost robot systems will need to demonstrate cost-effectiveness it is likely that smart tools and devices will have an increasing part to play in delivering better healthcare at lower cost. Robotic surgery is less of a revolution and more a process of evolution and its bright future in orthopaedic surgery is assured. n

Brian Davies is an Emeritus Professor of Medical Robotics at Imperial College London, where he has been since 1983, and is also a senior research investigator there. He has a PhD in Medical Robotics and a DSc. for Robotic and Computer Aided Surgery systems. He is a Fellow of the Royal Academy of Engineering since 2005. He developed the concept of Active Constraints in orthopaedic robots and in 1999 he was a co-founder of the spin-off company ACROBOT limited, who developed robots for MIS hip and knee joint replacement. He was their Technical Director until the company was acquired in 2010 by Stanmore Implants Worldwide, which in turn was bought by Mako Ltd and then by Stryker Ltd in 2013. In 2015 he was awarded the International Society of Technology in Arthroplasty (ISTA) life-time achievement award for research into the use of Robots in Surgery.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Subspecialty Section

Hydroxylapatite Coatings for Fixation of Orthopaedic Implants to Bone Professor Michael Manley, Visiting Professor in Biomechanics, University of Bath, Bath, UK Hydroxylapatite (HA), a form of calcium phosphate, is the mineral phase of bone and contributes about 40% to bone volume and 70% to bone weight. In the 1970s, in vivo studies of synthesized dense and porous forms of HA showed that it â&#x20AC;&#x2DC;becomes chemically bonded to bone via naturally-appearing bone cementing mechanismsâ&#x20AC;&#x2122;1. Subsequently, application of HA as a fixation coating for orthopaedic implants was developed in 1985 by Ronald Furlong in Britain2 and in 1986 separately by Rudolf Geesink in the Netherlands3.

Today, many thousands of HA coated total hip and knee components have been implanted worldwide. Clinical follow-up studies show rapid adaptation of bone to HA coated implant surfaces with impressive implant survivorship.

Basic Science

Professor Michael Manley

Calcium phosphate ceramics have been used to fill dental defects since 19814. However, the materials are brittle, with low tensile strength and poor impact resistance. For weight bearing implants the mechanical solution was to apply an HA coating to a metal substrate; the metal providing the mechanical strength and the HA coating the biological interface for

Examination of the bone/implant interface at high magnification shows bone bridges between bone and the HA surface (Figure 1). Implantation of uncoated control implants shows development of a seam of fibrous tissue between the implant and bone. Comparison of the mechanical strength of HA coated and uncoated implantbone interfaces confirms the superior mechanical properties of the coated devices4. Defects and gaps of up to 1mm at the fixation interface fill with bone in the presence of an HA coating7,8 with gap filling confirmed even in the presence of interface micromotion7,8,9. >>

bone attachment. Most often, HA is applied to metal using a high temperature plasma spray with an arc temperature of 30,000 degrees Kelvin. The HA powder is fed into the arc using argon as the carrier gas and is projected at high velocity onto the metal substrate5. For a hip stem, a coating of about 100 micrometers in thickness is built up in two minutes. Careful controls ensure that the final coating is primarily HA, rather than the more soluble betatricalcium phosphate. Studies of HA coated cortical plugs6, intra-medullary rods4 and hip implants6 in animals confirm that when implanted in bone, new bone forms directly on the HA surface and the bone adapts to the implant contours6.

Figure 1: Bone bridge between HA coated titanium alloy implant (left) and surrounding bone in a canine intramedullary implant (polarized light)

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JTO Subspecialty Section

Experimental evidence suggests that the longevity of HA coatings in vivo depends on coating density, crystallinity and purity10. Bone formation begins with dissolution of calcium and phosphate ions from the coating, followed by precipitation of carbonated apatite on the implant surface and new bone formation on both the coating and the bone surfaces11,12. For a plasma sprayed coating, high crystallinity of the HA is required for coating persistence in vivo, while a small quantity of tricalcium phosphate (<5%) in the coating allows enough dissolution to start bone formation. For implants with an ingrowth (porous) metal coating, animal studies show that a hydroxylapatite-tricalcium phosphate (HA-TCP) mixture applied to the porous metal by plasma spray accelerates bone ingrowth into the implant pores13. Solution deposition of HA on porous implants, with the coating nucleated and grown on the implant in solution, shows similar enhancement of bone ingrowth into porosities14. Plasma-sprayed HA and ingrowth HA-TCP coatings have been used with success in clinical studies. However, most long-term clinical studies are with on-growth coatings.

HA Coatings and Joint Replacement The first comprehensive articles documenting clinical findings with HA coated implants were published in 199315. Later reviews10,14,16 documented excellent survivorship of HA coated femoral stems at five, ten and fifteen-years. Longterm survival of on-growth HA stems at more than fifteen-year follow-up are available now in the literature17,18, with anecdotal reports of excellent survivorship at 25 year post-surgery. Radiographic studies of HA coated femoral hip stems show positive remodeling of bone and a

Figure 2: Radiographic sequence of an Omnifit-HA hip in a 44 year patient (at surgery) followed for 17 years. Cortical hypertrophy occurring between years 10 and 17 is shown (arrow). The patient continues to function well. (Radiographs courtesy of James D’Antonio MD)

“quiet” bone implant interface. Early bone remodeling stabilises until ten years post surgery19. Longer radiographic followup studies suggest that bone remodeling can begin again after ten years20 (Figure 2), perhaps because of reduced patient activity with age or because of age related mineral changes in the supporting bone. In the acetabulum, initial fiveyear results with HA coated acetabular components were disappointing. In comparison to HA coated threaded (screw) cups and to porous cups, smooth HA cups showed an unacceptable loosening rate21. Analysis of the cup interface suggested the smooth metal/HA/bone inferior to the acetabuum failed to withstand tensile stresses as the pelvis flexes during activity. The solution was to apply a roughened titanium ‘bond coat’ to the implant. This allowed mechanical interlock between the HA and the metal and interlock between the bone and the coating. Rough surface HA coated cups now show similar survivorship to that of HA coated hip stems22,23.

In the knee, HA coated total knee arthroplasties have been compared to controls that were fixed by cemented or porous fixation. Results suggest that HA coated tibial implants are more stable than their porous coated counterparts24. In a comparison study of HA coated versus uncoated grit-blasted tibial components, there were fewer radiolucencies with the coated implants (suggesting superior stability) but little difference in short term survivorship of the two designs25. An experimental fixation strategy to limit stress shielding by partially coating knee implants showed lucent radiographic lines in the uncoated areas, but excellent survivorship26. When used in unicondylar knees, an HA coating was shown to speed patient rehabilitation, improve bone adaptation to the implant and provide exceptional clinical survivorship27,28.

Discussion An early finding that an HA coating may be digested by osteoclastic activity caused concern for long-term implant survivorship29. The concern was

resolved by findings in autopsy specimens of new bone formation in intimate contact to implant contours29,30 and by radiographic reports of a continued stable implant/bone interface in the hip at more than fifteen years post implantation17,18. In the knee, HA coated tricompartmental knee replacements are successful but do not show any clear advantage over cement fixation. For HA coated unicompartmental knee replacements results are superior to cemented designs. In general, patients with HA coated implants report more rapid recovery than recovery with other cementless fixation strategies. At least in the hip, this rapid patient rehabilitation, positive bone remodeling and superb very long-term survivorship suggests that HA coated implants are the gold standard that others must reach. n Michael Manley FRSA, PhD was, until recently, the Chief Scientific Advisor to Stryker Orthopaedics in Mahwah, New Jersey, USA. He retired from that position in December 2016 and now is the President of his own company (Michael T. Manley FRSA, PhD, LLC) specialising in providing consulting services in Biomechanics, Biomaterials and Clinical Research. Since 2007, he has been a Visiting Professor at the University of Bath, UK. He continues to publish the results of clinical studies as well as manuscripts that describe the impact of Federal health policy on the outcomes of hip and knee replacement in the US.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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In Memoriam

Gordon Waddell CBE, D.Sc. MD FRCS 21st September 1942 - 20th April 2017 Gordon Waddell, the pioneering orthopaedic surgeon who played a seminal role in the biopsychosocial approach to understanding and managing back pain has died aged 74. Gordon was an extraordinary scientist and communicator, with an uncanny ability to synthesise complex information and present it in a way that changed how people did things. His impact has been worldwide.

Gordon Waddell CBE, D.Sc. MD FRCS

Gordon’s keen clinical observation and tremendous capacity for careful data collection and analysis served as the foundation for a novel approach to clinical assessment to disentangle physical, psychological and behavioural aspects. This evolved into the biopsychosocial model of low back disability that underpins current clinical practice. Indeed, Gordon was instrumental around the world in setting out the evidence debunking the use of bed rest as a treatment. This included a major contribution to the occupational health guidelines for managing back pain at work, published in 2000 by

the Faculty of Occupational Medicine, from whom he later received an Honorary Fellowship. Next, Gordon deliberately escaped his primary discipline and redirected his energy into tackling the social and occupational aspects of disability. There followed a series of major policy reviews commissioned primarily by the UK Government. Predominant among these was the 2006 report presenting the evidence that ‘good’ work is beneficial for health and wellbeing. In 2009 Gordon chose to retire from academic life to spend more time with his family. In typical style, he quietly waved goodbye as he left a conference podium to catch his plane back to Glasgow. Gordon wrote a seminal book on back pain - The Back Pain Revolution. It is a sublime example of how to communicate complex and sometimes contentious ideas. Perhaps more than any other single publication this book has changed the way back pain is treated and managed.

The influence that Gordon had on the worlds of pain, work, rehabilitation, and policy was recognised with a raft of honours in numerous countries. He was regularly consulted for advice on disability management by government departments and clinical organisations across the globe. Gordon was a tenacious researcher and visionary, who thoroughly enjoyed the altercations that come from pushing the boundaries of science and understanding. Despite all his professional achievements, Gordon also restored a 17th Century cottage in the Scottish Highlands and wrote a 500-year history of the glen (Highland Roots, 2013). He loved hill walking, and did much thinking out on the mountains; in typical style he asked for his climbing boots to adorn his coffin! Gordon was a family man, and it is fitting that in his later years he had the opportunity to enjoy precious time with his wife Sandra, their three daughters (Carol, Joyce and Hazel), and the grandchildren.

Remember them fondly

It is with great sadness that we report the passing of the following members. Our thoughts are with their families and friends at this time.

Mr Mirza Baig Dr Aloysio Campos Da Paz Junior Mr Norman McLeod Mr Robert Phillips Professor Arturo Saldana

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